Methods, compositions, unit dosage forms, and kits for pharmacologic stress testing with reduced side effects

ABSTRACT

Methods are presented for concurrent or sequential administration of pharmaceutical compositions of adenosine, dipyridamole, or combinations thereof, at dosages below the respective single agent doses. Methods are provided for detecting the presence and/or assessing the severity of myocardial ischemia during pharmacologic stress tests. Methods include sequential administration of a dipyridamole bolus followed by intravenous infusion of adenosine and concurrent administration of adenosine and dipyridamole with or without dipyridamole pretreatment. The methods are useful for exploiting the vasodilating abilities of adenosine at doses at which side effects related to adenosine are substantially reduced while optimal coronary artery perfusion is achieved. Also presented are compositions, unit dosage forms, and kits that are useful in performing the methods.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims benefit under 35 U.S.C. §119(e) to U.S.provisional application Ser. No. 61/085,791, filed 1 Aug. 2008, and U.S.provisional application Ser. No. 61/022,695, filed 22 Jan. 2008, thedisclosures of which are incorporated herein by reference in theirentireties.

1. BACKGROUND

Functional assessment of myocardium, in particular the evaluation of themyocardium's oxygen status, is important in guiding therapeuticdecisions in the care of patients with cardiac ischemia. In currentclinical practice, myocardial ischemia status is most often assessedusing non-invasive nuclear perfusion imaging methodologies, such asplanar scintigraphy or single photon emission computed tomography(SPECT), with thallium and technetium as the most frequently usedisotopes. Presently, other types of imaging that entail less exposure toradiation and/or provide improved visualization of myocardium arebecoming available. Positron emission tomography (PET) with rubidium-82,³N-ammonia (¹³NH₃), or ¹⁵O-labeled water (H₂ ¹⁵O), has been gainingrecognition as providing improved images with less radiation. Anothertechnology, myocardial contrast echography (MCE), uses agents detectableby ultrasound to study myocardium perfusion and heart function in realtime with a single test. Doppler echography, either semi-invasivetransesophageal doppler echography or non-invasive transthoracic dopplerechocardiography, allows examination of the motion of ventricular wallsand measurement of coronary flow reserve. Yet another imagingtechnology, X-ray computed tomography (CT) scanning, has been used instudying myocardial perfusion possibly coupled with coronary angiograms.High speed CT scanners, such as ultrafast CT scanners, are capable oftaking multiple images of the heart within the time of a singleheartbeat. Recently, this technology has been further improved usingdual-energy imaging leading to the development of ultra high speed CTscanners, such as the Somatom Definition Flash, capable of scanning anentire human thorax in 0.6 seconds, and heart in 250 milliseconds,thereby reducing radiation exposure and permitting repeated scanningunder various conditions for myocardial perfusion imaging (MPI) studies.

Each of these functional tests typically require that the patient'sheart be “stressed” in order to assess cardiac function. Such stress canbe induced either through controlled exercise or by pharmacologic means.These tests are commonly referred to as “stress tests”. Pharmacologicalstressors for functional assessment of myocardium act through coronaryvasodilation: by dilating normal vessels to a greater extent thandiseased vessels, these agents establish a shunt, or “myocardial steal”,that produces differential increases in blood flow in healthy vs.diseased arteries in patients with coronary artery disease, optimizingthe discriminatory imaging of cardiac muscle areas in need of oxygensupply.

Adenosine and dipyridamole are coronary vasodilators, each of which isseparately approved for individual use as a pharmacologic stressor forstress testing. Adenosine acts directly by stimulating adenosinepurinergic P1 receptors on the arterial wall. Dipyridamole is believedto work indirectly by blocking reuptake of adenosine at the cellularlevel, leading to an increase in endogenous adenosine concentration inthe blood. Dipyridamole produces similar near-maximal coronary hyperemiato that produced by exogenous adenosine, but less quickly.

To ensure near-maximal coronary vasodilation, and to provide sufficienttime for the acquisition of cardiac images, adenosine is infused for 6minutes at a dosage rate of 140 μg/kg patient body weight/min;dipyridamole is infused for 4 minutes at 140 μg/kg patient bodyweight/min. Thus, the total recommended dose of adenosine is 0.84 mg/kg,and the total recommended dose for dipyridamole is 0.56 mg/kg at theminimum and 0.80 mg/kg on average in a 4 minute infusion. Ifvasodilation is insufficient, the total dose of dipyridamole can beincreased up to 0.95 mg/kg, administered over a 6 minute infusion.

Although infused for only a few minutes, compounds that stimulateadenosine receptors are accompanied by numerous uncomfortable adverseeffects. With adenosine, the most frequently reported are flushing(44%), chest pain or chest discomfort (40%), dyspnea (28%), headache(18%), throat or neck or jaw discomfort (15%), and gastrointestinaldiscomfort (13%); other side effects (e.g., atrioventricular blocks) areless frequent.

The adverse effects of adenosine are dose-dependent. Symptoms such asheat sensation, flushed face, dyspnea and chest pain increase asadenosine dosage is increased from 60 to 140 μg/kg/min, in a six minuteinfusion. Chest pain typically appears at doses of 90 μg/kg/min, andbecomes frequent at 120 μg/kg/min. At a dosage of 70 μg/kg/min or less,it has been noted that adenosine adverse reactions are very few and ofmild intensity. However, when administered by intravenous perfusion at70 μg/kg/min or less, or even at 90-120 μg/kg/min, adenosine showsreduced efficacy, and is not recommended for stress testing at suchreduced dosages.

The side effect profile of dipyridamole is similar, but with adverseevents occurring less often. However, dipyridamole side effects lastlonger, are more difficult to manage, and thus more frequently requireextra patient monitoring time and the administration of intravenousaminophylline as an antidote.

Because dipyridamole is understood to act by increasing endogenousadenosine, use of both adenosine and dipyridamole at full intravenousdosage is contraindicated. Similarly, oral intake of dipyridamole priorto an adenosine pharmacologic stress testing is generally avoided.

In an effort to reduce side effects at maximally effective agonistdoses, adenosinergic agents are being developed that are selective forthe A2a receptor subtype. See, e.g., U.S. Pat. Nos. 6,531,457;6,448,235; 6,322,771; and 5,877,180. Specific compounds either recentlyapproved by FDA or still in development include regadenoson, binodenosonand apadenoson. However, despite increased receptor selectivity, theseadenosinergic agents also exhibit side effects unrelated to activity onthe A2a receptor, due to their incomplete selectivity. The overallreduction of side effects remains modest and sometimes, as is the casefor regadenoson, show an increase in frequency and severity of sideeffects. Regadenoson treatment, for example, results in an increase indyspnea, headache and gastrointestinal disorders as compared totreatment with the reference drug Adenoscan (adenosine). These compoundsalso have a longer duration of action than adenosine (e.g 10±6 minutesfor binodenoson) due to a tighter affinity to A2a receptor. Accordingly,the A2a-related side effects, e.g., flushing, headache, and dyspnea, arelonger lasting. Thus, although more specific than adenosine, theseagents may be more likely to trigger prolonged side effects requiringadministration of pharmacologic antidotes, than adenosine itself, whoseside effects rapidly dissipate once administration is stopped.Additionally, these products (e.g., Regadenoson) may induce directsympathetic stimulation, in particular an increase in heart rate that isgreater than that observed with adenosine. Therefore the potential riskof ventricular arrhythmia in severe coronary patients should not beunderestimated and could pose safety problems in the future.

There thus exists a continuing need in the art for injectable agentsthat can be used for pharmacologic stress testing, that have the rapidonset and short half-life of adenosine, and thus can be managedclinically in the same manner as adenosine, and that provide maximalefficacy with reduced side effects.

2. SUMMARY

Dipyridamole is believed to act indirectly by increasing endogenousadenosine concentration. In clinical practice, the compound has a sideeffect profile similar to that of adenosine, and is also known topotentiate exogenous adenosine adverse events to such an extent that itscombination with adjunctively administered adenosine is normallycontraindicated (“drugs that augment the effects of adenosine should bewithheld for at least five half-lives prior to the use of Adenoscan”,quoted from the US FDA-approved Adenoscan drug label). However, I havediscovered that extremely low parenteral doses of dipyridamole—on theorder of 5% of the dose now used clinically in cardiac imagingstudies—can surprisingly ensure optimal vasodilation effects ofadjunctively administered adenosine without commensurate potentiation ofadenosine's side effects. See commonly assigned U.S. patent applicationSer. No. 11/772,784, and international application no.PCT/EP2007/005923, published as WO 2008/003479, the disclosures whichare incorporated herein by reference in their entireties. This allowsuse of adenosine at reduced dosages to effect coronary vasodilation,e.g., for functional assessment of myocardial function, and providesequal or superior efficacy as compared to current protocols whilereducing side effects. Moreover, the clinical and hemodynamic effectsadvantageously stop less than one minute after cessation of adenosineadministration.

Accordingly, described herein are methods, compositions, unit dosageforms and kits that use subclinical doses of dipyridamole, lackingsignificant hemodynamic and clinical effect when used alone, to modulateeffects of adjunctively administered adenosine, (i) permitting reductionin the exogenous adenosine administered dose, and (ii) reducing relatedadverse events incidence and severity, while maintaining the sameefficacy and duration of action as adenosine at its recommended singleagent dosage.

In one aspect, methods are provided for effecting coronary vasodilationfor cardiac diagnosis.

In various embodiments, the methods comprise: (i) parenterallyadministering an adenosine modulator, such as dipyridamole; and (ii)sequentially thereafter parenterally administering an adenosine receptoragonist, such as adenosine. Each of dipyridamole and the adenosinereceptor agonist is administered at a dosage lower than that requiredfor maximal coronary vasodilation when administered as a single agent byidentical parenteral route.

In some embodiments, the adenosine receptor agonist is selected from:adenosine, adenosine triphosphate (ATP), adenosine diphosphate (ADP),adenosine monophosphate (AMP), and pro-drugs and pharmaceuticallyacceptable salts of adenosine or AMP, ADP, ATP. Whatever the identity ofthe adenosine receptor agonist, the ratio between adenosine or theadenosine agonist and dipyridamole is about 2:1 to 10:1 and preferably7:1.

Each route of parenteral administration may be independently selectedfrom: intra-arterial, intravenous, and atrial administration.

In some embodiments, dipyridamole is administered by intravenous orintra-arterial bolus injection. In certain embodiments, dipyridamole isadministered as an intravenous or intra-arterial bolus at a dosage of nomore than about 140 μg/kg, no more than about 50 μg/kg, even no morethan about 40 μg/kg, and typically at a dosage of at least about 14μg/kg. For example, in some embodiments, dipyridamole is administered asan intravenous or intra-arterial bolus at a dosage of about 23 to about60 μg/kg, such as about 35 μg/kg or about 40 μg/kg which is thepreferred dosage.

In some embodiments dipyridamole is administered as an intravenous bolusimmediately followed by the intravenous infusion of adenosine.Immediately means as soon as clinically practicable, typically withinabout 2 to 30 seconds.

In various embodiments dipyridamole is administered as a 5 to 30 secondbolus prior to adenosine infusion of about 1 to about 6 minutes.

In a variety of embodiments, the adenosine receptor agonist isadministered intravenously over about 2 or about 3 minutes followingdipyridamole bolus injection.

In some embodiments, dipyridamole is administered by intravenousinfusion over about 1 or about 4 minutes.

In some embodiments, the adenosine receptor agonist administration isbegun after completion of dipyridamole administration, such as betweenabout 30 seconds and about 2 minutes after dipyridamole injection orinfusion.

In typical embodiments, the adenosine receptor agonist is adenosine,administered by intravenous infusion at a dosage rate of about 35μg/kg/min-100 μg/kg/min. In these embodiments, adenosine is administeredat a dosage rate of no more than about 100 μg/kg/min. In someembodiments, adenosine is administered at a dosage rate of no more thanabout 70 μg/kg/min, even no more than about 50 μg/kg/min. In exemplaryembodiments, the adenosine receptor agonist is adenosine, administeredby intravenous infusion at a dosage rate of at least about 35 μg/kg/min,even at least about 50 μg/kg/min. For example, in some embodiments,adenosine is administered by intravenous infusion at a rate of about 50μg/kg/min to about 70 μg/kg/min which is the preferred dosage.

In certain embodiments, the adenosine receptor agonist is adenosine, thetotal dose of dipyridamole is 23 to 40 μg/kg, and the dosage rate foradenosine is 50 to 70 μg/kg/min. For example, in some embodiments, thetotal dose of dipyridamole is 40 μg/kg and the dosage rate for adenosineis 70 μg/kg/min.

In a variety of embodiments, adenosine and dipyridamole are administeredby intravenous infusion. In some embodiments, adenosine is administeredinto a coronary artery at a dose of about 10 to about 20 μg/min,regardless of patient weight, after intravenous bolus injection ofdipyridamole at a dose of about 20 to about 40 μg/kg, preferably 40μg/kg.

In certain embodiments, the method usefully comprises the step ofassessing cardiac function. Assessing cardiac function may include useof one or more techniques selected from: electrocardiography, M modeechography, two dimensional echography, three dimensional echography,echo-doppler (e.g., Transthoracic echo-doppler), cardiac imaging, planar(conventional) scintigraphy, single photon emission computed tomography(SPECT), dynamic single photon emission computed tomography, positronemission tomography (PET), first pass radionuclide angiography,equilibrium radionuclide angiography, nuclear magnetic resonance (NMR)imaging, myocardial perfusion contrast echocardiography (MCE orreal-time MCE), digital subtraction angiography (DSA), x-ray computedtomography (CINE CT), including high speed and ultra high speed CTscanning. In certain embodiments, functional assessment is specificallyperformed by SPECT; in other embodiments, the assessment is specificallyperformed by PET. In other embodiments the assessment is specificallyperformed by MCE. In other embodiments it is specifically performed byCT scan, including high speed and ultra high speed CT scan.

In some embodiments, assessing cardiac function includes parenteraladministration of an isotope, and the isotope is administered no lessthan 1 minute but before 2.75 minutes. In some embodiments the isotopeis delivered after 1.1 minute, after 1.2 minute, after 1.3 minute, after1.4 minute, after 1.5 minute, after 1.6 minute, after 1.7 minute, after1.8 minute, after 1.9 minute, after 2 minutes (which is the preferredmethod), after 2.1 minutes, after 2.2 minutes, after 2.3 minutes, after2.4 minutes, after 2.5 minutes and always before 2.75 minutes, whendipyridamole and the adenosine receptor agonist are administeredsequentially.

In some embodiments, the method may comprise the step of assessingcardiac function using the injection or formation of contrast agentsdetected by ultrasound techniques in a period of time ranging from 10seconds to 3 minutes. These techniques may include parenteraladministration of an agent such as, hydrophobic drugs and/or polymers(e.g polyethylene glycol), in the form of microspheres or nanospheresand/or microbubbles made of gas including air or compositions comprisingcombinations of these agents (e.g. perflubutane polymers)

In one aspect, methods of effecting coronary vasodilation for cardiacdiagnosis are provided. The methods comprise concurrently administeringan adenosine receptor agonist, such as adenosine, and an adenosinemodulator, such as dipyridamole. In various embodiments, adenosine anddipyridamole are administered parenterally at an adenosine:dipyridamoleweight ratio of about 2:1 to about 10:1.

In certain embodiments, a small fraction of the total dipyridamole doseis used as a priming dose—acting as a pretreatment—preceding theconcurrent administration of dipyridamole with adenosine.

In certain embodiments, the adenosine:dipyridamole ratio is about 2:1 toabout 4:1, for example 4:1, or about 8:1, or preferably 7:1.

In various embodiments, adenosine is administered at a dosage rate ofabout 35 to 100 μg/kg/min and dipyridamole is administered at a dosagerate of about 3.5-50 μg/kg/min. In some embodiments, adenosine isadministered at a dosage rate of about 70 μg/kg/min and dipyridamole isadministered at a dosage rate of about 10 μg/kg/min (which is thepreferred combination dose); adenosine is administered at a dosage rateof about 70 μg/kg/min and dipyridamole is administered at a dosage rateof about 8.75 μg/kg/min; adenosine is administered at a dosage rate ofabout 50 μg/kg/min and dipyridamole is administered at a dosage rate ofabout 12.5-25 μg/kg/min.

Adenosine and dipyridamole may be parenterally administered continuouslyfor a period of at least about 1 minute, typically less than about 6minutes. In certain embodiments, adenosine and dipyridamole areparenterally administered continuously for a period of about 3 or 4minutes. In other embodiments for a period of about 1 to 2 minutes.

In some embodiments of the methods presented herein, adenosine anddipyridamole are administered as a single composition. In someembodiments, adenosine and dipyridamole are administered concurrentlyfrom separate compositions. In certain embodiments, two modes arecombined (e.g. a dipyridamole priming dose is administered using adipyridamole unit dosage form, followed by administration of a unit doseof a combined composition).

In certain embodiments, the method usefully comprises the step ofassessing cardiac function. Assessing cardiac function may include useof one or more techniques selected from: electrocardiography, M modeechography, two dimensional echography, three dimensional echography,echo-doppler (e.g., Transthoracic echo-doppler), cardiac imaging, planar(conventional) scintigraphy, single photon emission computed tomography(SPECT), dynamic single photon emission computed tomography, positronemission tomography (PET), first pass radionuclide angiography,equilibrium radionuclide angiography, nuclear magnetic resonance (NMR)imaging, myocardial perfusion contrast echocardiography (also calledreal-time MCE), digital subtraction angiography (DSA), x-ray computedtomography (CINE CT), including high speed and ultra high speed CTscanning. In certain embodiments, functional assessment is specificallyperformed by SPECT; in other embodiments, the assessment is specificallyperformed by PET. In other embodiments the assessment is specificallyperformed by MCE. In other embodiments it is specifically performed byCT scan, including high speed and ultra high speed CT scan.

In certain embodiments of the methods that comprise assessment ofcardiac function, assessing cardiac function includes parenteraladministration of an isotope. The isotope is typically administered noless than about 1 minute and no more than about 3 minutes after theconcurrent parenteral administration of adenosine and dipyridamole hasbegun. In some embodiments isotope can be administered no less than 1.1minute, no less than 1.2 minute, no less than 1.3 minute, no less than1.4 minute, no less than 1.5 minute, no less than 1.6 minute, no lessthan 1.7 minute, no less than 1.8 minute, no less than 1.9 minute, noless than 2 minutes, no less than 2.1 minutes, no less than 2.2 minutes,no less than 2.3 minutes, no less than 2.4 minutes, no less than 2.5minutes, no less than 2.6 minutes, no less than 2.7 minutes, no lessthan 2.8 minutes, no less than 2.9 minutes after the concurrentadministration of adenosine and dipyridamole has begun. In otherembodiments, where a fraction of the dipyridamole total dose (primingdose) is administered prior to the concurrent administration mode, theisotope is injected after only 2 minutes and always before 2.5 minutes.

In other embodiments, the methods comprise assessing myocardialperfusion and function by transthoracic doppler-echography or myocardialperfusion contrast echography; myocardial perfusion contrastechocardiography (real-time MCE) may include parenteral administrationof an agent detectable by ultrasound techniques such as, but not only,hydrophobic drugs and/or polymers (e.g polyethylene glycol), in the formof microspheres or nanospheres and/or microbubbles made of gas includingair or compositions comprising combinations of these agents (e.g.perflubutane polymers).

In some aspects, pharmaceutical compositions comprising adenosine anddipyridamole are presented. The compositions comprise adenosine anddipyridamole in adenosine:dipyridamole weight ratios of about 2:1 toabout 10:1, such as about 2:1 to about 4:1. In some embodiments, theratio is about 8:1 and preferably 7:1.

In various embodiments, adenosine and dipyridamole are present inamounts that permit adenosine to be administered at a dosage rate ofabout 35 to about 100 μg/kg/min and dipyridamole to be administered at adosage rate of about 3.5 to about 50 μg/kg/min.

In various embodiments adenosine is administered at a dosage rate ofabout 70 μg/kg/min and dipyridamole at a dosage rate of about 10μg/kg/min.

In various embodiments, the composition may be a sterile fluid, such asa sterile fluid suitable for parenteral administration, such asintravenous administration. Its pH is generally acid (2 to 4). In someembodiments, adenosine and dipyridamole are present at concentrationsthat permit direct intravenous administration and immediate dilutioninto the venous line.

In various embodiments, adenosine and dipyridamole are present atconcentrations that permit administration of adenosine at a dosage rateof about 70 μg/kg/min and dipyridamole at a dosage rate of about 8.75 toabout 10 μg/kg/min. In some embodiments, adenosine and dipyridamole arepresent at concentrations that permit administration of adenosine at adosage rate of about 50 μg/kg/min and dipyridamole at a dosage rate ofabout 12.5 to about 25 μg/kg/min.

In a range of embodiments of the pharmaceutical compositions hereprovided, the concentration of adenosine is about 1 to 10 mg/ml.Usefully, the concentration of adenosine is about 3 mg/ml or 4 mg/ml,even 5 mg/ml, or 7 mg/ml.

In certain embodiments, the concentration of dipyridamole is about 0.1to 4 mg/ml, such as: 3 mg/7 ml and 6 mg/14 ml (0.43 mg/ml), 4 mg/7 mland 8 mg/14 ml (0.57 mg/ml), 5 mg/7 ml (0.71 mg/ml), 6 mg/7 ml (0.85mg/ml) or 1 mg/ml as shown in Table 1, hereinbelow.

In various embodiments of pharmaceutical compositions comprisingadenosine, either as sole active, or in combination with dipyridamole,the composition has a pH less than about 4.5, less than about 4.4, lessthan about 4.3, less than about 4.2, less than about 4.1, less thanabout 4.0, less than about 3.9, less than about 3.8, less than about3.7, even less than about 3.6, including intermediate nonintegral pHvalues there between. In certain embodiments, the pH is between about 2and 4.

In one aspect, unit dosage forms are provided that containpharmaceutical compositions as above-described, comprising adenosine anddipyridamole.

In some embodiments, the unit dosage form contains about 2 to 50 ml ofthe pharmaceutical composition formulated as a sterile fluid, typicallya sterile, nonpyrogenic, solution suitable for parenteraladministration. In some embodiments, the unit dosage form contains about2 ml, 3 ml, 4 ml, 5 ml, 6 ml, 7 ml, 8 ml or 14 ml (see Table 1).

In some embodiments, the unit dosage form contains about 5 to 60 mg ofadenosine and about 0.5 to 30 mg of dipyridamole; the composition is asolid capable of sterile reconstitution in a physiologically acceptablesolvent or solution.

In exemplary embodiments, the unit dosage form contains about 14 mg ofadenosine and about 2 mg of dipyridamole, about 21 mg of adenosine andabout 3 mg of dipyridamole; about 28 mg of adenosine and about 4 mg ofdipyridamole; about 35 mg of adenosine and about 5 mg of dipyridamole;about 42 mg of adenosine and about 6 mg of dipyridamole; about 56 mg ofadenosine and about 8 mg of dipyridamole.

In some embodiments, the unit dosage forms are usefully prefilledsyringes.

In some embodiments the unit dosage forms are vials with compositionsthat can be sampled using empty syringes of standard 10, 15, 20, andeven 30 ml total capacity. In various embodiments, the barrel of thesyringe—whether prefilled or not—is usefully labeled with weight (e.g.,kilograms or pounds) graduation marks so as to facilitateweight-adjusted dosing of the active.

In some embodiments, the weight graduation scale is in kilograms (kiloor kg). In certain embodiments, kilo graduation scales range from 10 or40 kilograms up to 100 or 125 or 133 or 150 or 166 or even 200kilograms, depending on the syringe capacity. Milliliter per kilogramequivalence can range typically from 0.01 ml=1 kg to 0.2 ml=1 kgdepending on the dose, the volume of liquid in the syringe, and therecommended infusion time. In some embodiments, the graduation scale issuch that a one kilogram interval can equal 0.03 ml, or 0.04 ml or 0.042ml, or 0.0525 ml, or 0.056 ml, or 0.07 ml, according to needs and thefeatures of the syringe used. In some embodiments, syringes are providedwith a weight graduation scale in pounds.

In another aspect, unit dosage forms of dipyridamole are provided. Invarious embodiments, dipyridamole is provided in solution at aconcentration of about 0.1 to 4 mg/ml.

In certain embodiments, the dipyridamole concentration is usefully about3 to 4 mg/ml. Among these embodiments are unit dosage forms atconcentrations of 3 mg/ml or 4 mg/ml in volumes of 1 ml or of 2 ml,providing unit dosage forms comprising 3 mg dipyridamole in 1 ml, 6 mgdipyridamole in 2 ml, 4 mg in 1 ml and 8 mg dipyridamole in 2 ml.

In some embodiments, the dipyridamole concentration is 1 mg/ml or 2mg/ml.

In some embodiments the dipyridamole unit dosage forms are prefilledsyringes, optionally with kilo graduation marks on their cylinder tofacilitate weight-adjusted dosing. The scale of such a graduation marks,provided in some embodiments by an affixed label, can range, forexample, from 10-40 to 100 or 200 kilograms with an interval of 1kilogram=0.01 ml whatever the features of the syringe used.

In one aspect, unit dosage forms of adenosine are provided. In someembodiments, unit dosage forms are formulated in sterile fluidcomposition, and dose packaging permits sterile introduction of a secondfluid in a volume at least 15% that of the adenosine composition. Insome embodiments, the second fluid usefully comprises dipyridamole (see,e.g., Table 2 and FIG. 5).

In exemplary embodiments, the unit dosage form contains 21 mg adenosinein 6 ml; 28 mg adenosine in 6 ml; 42 mg adenosine in 12 ml; or 56 mgadenosine in 12 ml (see Table 2).

In certain embodiments, the composition in the unit dosage form has a pHless than about 4.5, less than about 4.4, less than about 4.3, less thanabout 4.2, less than about 4.1, less than about 4.0, less than about3.9, less than about 3.8, less than about 3.7, even less than about 3.6,including intermediate nonintegral pH values therebetween. In certainembodiments, the pH is between about 2 and 4.

In certain exemplary embodiments of the methods presented herein, unitdosage forms of adenosine are administered immediately after adipyridamole bolus injection. In some embodiments unit dosage forms(vials or prefilled syringes) contain 14 mg adenosine in 10 ml, 21 mgadenosine in 10 ml, 28 mg adenosine in 10 ml, 35 mg in 15 ml, 42 mg in20 ml, 56 mg in 20 ml. In some embodiments adenosine is at aconcentration of about 3 mg/ml, with 21 mg adenosine in 7 ml or 42 mgadenosine in 14 ml, or the unit dosage form may comprise adenosine at 4mg/ml with 28 mg adenosine in 7 ml or 56 mg adenosine in 14 ml.

In some embodiments, when the unit dosage forms are in the form ofprefilled syringes, the barrel of these syringes can usefully be labeledwith weight graduation marks to permit convenient weight-adjusteddosing. In some embodiments, the weight graduation scale is inkilograms. These kilo graduation scales can go from 10 or 40 kilogramsup to 100 or 125 or 133 or 150 or 166 or even 200 kilograms depending onthe syringe capacity. Milliliter per kilogram equivalence can range from1 kilogram=0.0005 ml, to 1 kilogram=1 ml regardless of the syringecharacteristics and more typically from 1 kilogram=0.01 ml, to 1kilogram=0.2 ml. In some embodiments, the milliliter per kg equivalenceis of 0.06 ml or 0.075 ml or 0.08 ml or 0.09 ml or 0.1 ml or 0.12 ml,regardless of the syringe characteristics.

In one embodiment, adenosine at a concentration of 3 mg/ml is providedin a prefilled syringe with weight graduation marks that contains 30 mgadenosine in a volume of 10 ml. In one embodiment, a prefilled syringecomprises a label with a kilo graduation scale where a 1 kg interval isequivalent to 0.07 ml if infusion time is 3 minutes, the 7 ml markingequals 100 kg (or the dose for a patient weighing 100 kg) and the 10 mlmarking equals 130 kilograms (129.870 kgs).

In some embodiments, the unit dosage form comprises a pre-filled syringecomprising 60 mg adenosine in a volume of 20 ml. In some embodiments,the unit dosage form comprises a pre-filled syringe comprising 90 mgadenosine in a volume of 30 ml. The pre-filled syringe, in variousembodiments, further comprises labels as described herein.

In some embodiments, unit dosage forms of adenosine are administered inparallel with dipyridamole through separate interdependent (yoked)syringes (see, e.g., FIG. 6). In these embodiments, the unit dosage formof adenosine and the unit dosage form of dipyridamole may each compriseany of the prefilled syringes described herein.

In certain of these embodiments a specific connector is used so that afraction of the dipyridamole dose flows into the venous line prior toadenosine, thereby serving as priming dose. The connector also serves asa mixer when, immediately after this priming dose, the concurrentinfusion of the two drugs becomes effective.

Also provided are kits. The kits comprise at least one unit dosage formof dipyridamole and at least one unit dosage form of adenosine. The unitdosage forms can be prefilled syringes. In some embodiments, the atleast one unit dosage form of dipyridamole is a unit dosage form asabove-described, and the unit dosage form of adenosine is a unit dosageform as above-described. Adapted connectors and extension set/venouslines are usefully included in the kits.

In some kit embodiments the kit comprises one unit dosage form of theadenosine:dipyridamole composition. In other embodiments the kitscomprise at least one unit dosage form of adenosine and at least oneunit dosage form of dipyridamole. The unit dosage forms can be prefilledsyringes. In some embodiments, the at least one unit dosage form ofadenosine:dipyridamole composition is a unit dosage form asabove-described, and the unit dosage forms of dipyridamole and ofadenosine are unit dosage forms as above-described. Adapted connectors,diluent (e.g. saline) and extension set/venous lines are usefullyincluded in the kits.

In summary, adenosine (Adenoscan, sold by Astellas) is the standardpharmacological stressor used in cardiac imaging to induce near-maximalcoronary vasodilation. At its recommended dosage rate of 140 μg/kg/min,its use is attended by numerous uncomfortable side effects. The datafrom the studies presented herein demonstrate that the sequential bolusadministration of dipyridamole at 28-40 μg/kg—well below the total doseinfused when dipyridamole is used as a single agent stressor—followed byinfusion of adenosine at 70 μg/kg/min, is equally efficacious inproviding coronary vasodilation for imaging studies, while causing fewerside effects. The data also demonstrate that dipyridamole and adenosinemay be combined in a single infusion (in particular 10 μg/kg/mindipyridamole with 70 μg/kg/min adenosine), over 4 minutes and possiblyover a 3 minute or even 2 minute period, to similar effect. Among theside effects reduced by the combination of the present invention arechest pain and the risk of significant heart blockage.

3. BRIEF DESCRIPTION OF THE DRAWINGS

The above and other objects and advantages of the present invention willbe apparent upon consideration of the following detailed descriptiontaken in conjunction with the accompanying drawings, in which likecharacters refer to like parts throughout, and in which:

FIGS. 1A-1E present exemplary embodiments of labels for weight-adjusteddosing of pharmaceutical compositions according to embodiments of thepresent invention. FIG. 1A shows an exemplary syringe with label forweight-adjusted dosing. The barrel of the syringe unit (010) contains ascale (020) having graduation marks on one or both sides. A double scaleis shown having marks for measurements in two different units, volumeand weight. Any known unit of weight can be used for the weightgraduation scale on a label, including but not limited to, kilograms(kg) or pounds (lbs). The inset shows an expanded view of a double scalewith graduation marks for two measurements, volume and weight. FIG. 1Billustrates that the weight scale in various embodiments can range aslow as 10 kilograms, approximately 22 pounds, or an equivalent weight inany other known unit of measurement. FIG. 1C illustrates that weightgraduations can range up to any desired maximum, for example, weights of150 and 200 kg, respectively. Equivalent weight graduation scales arepossible in other units of measurement, including pounds (such as 330 or440 lbs, respectively, for the example provided). FIG. 1D provides anexample of dual volume and weight scale, with offset graduations. Insome embodiments, the label comprises both a volume and a weight scale,which are offset relative to each other. FIG. 1E illustrates an exampleof a label having a single scale with units of weight, in kilograms.Labels comprise at least a weight scale for dosing. In some cases, thescale is provided in units of pounds;

FIGS. 2A and 2B illustrate exemplary syringe labels withkilogram-graduation scales for use in sequential administration ofpharmaceutical compositions according to embodiments of the presentinvention. FIG. 2A illustrates an exemplary labeled syringe useful ininitial administration of a bolus of dipyridamole (4 mg in 1 ml unitdosage form, “UDF”), dose 40 mg/kg, according to various embodiments ofthe methods of the present invention. Two different examples of labelsare provided, one with a 40 to 100 kg scale, and the second with a 10 to100 kg scale. In each case, the scale is calibrated such that 0.01 ml isadministered for every kilogram of patient weight. FIG. 2B illustratesan exemplary labeled syringe useful in adenosine infusion to be madesubsequent to the dipyridamole administration, according to variousembodiments of the methods of the present invention. In these examples,adenosine (28 mg per 10 ml UDF) is infused, dose 70 mg/kg/min. Twodifferent examples are shown, one for a 4-minute infusion and the secondfor a 3-minute infusion. In the 4-minute infusion, the scale iscalibrated such that 0.1 ml is administered for every kilogram ofpatient weight. For a 3-minute infusion, the scale is calibrated suchthat 0.075 ml is administered for every kilogram of patient weight;

FIGS. 3A and 3B illustrate an example of sequential administration,according to various embodiments of the present invention. In FIG. 3A.,dipyridamole is injected intravenously, e.g. as a 5- to 30-second bolus(mean injection time 5-10 seconds), via Y-connector leading to anintravenous line. In FIG. 3B, adenosine is infused immediatelysubsequent to dipyridamole administration using a programmable deliverydevice, such as an electric pump. Typical infusion times includeinfusions of 3 and 4 minutes;

FIGS. 4A-4C illustrate the exemplary adjustment and individualization,prior to use, of an exemplary prefilled syringe unit dosage containing acombined composition of adenosine and dipyridamole. In FIG. 4A, dose isfirst adjusted based on patient weight, given the amount of each of theactives in the prefilled syringe. In the exemplary embodiment shown, a10-ml syringe is provided prefilled with 28 mg adenosine and 4 mgdipyridamole in a 4 ml volume. In FIG. 4B, saline is added, e.g. toadjust pH in embodiments in which the combined composition has an acidicpH. In certain embodiments, the optimum ratio of saline solution tocomposition comprising the actives is about 1:2. As shown in theexample, at least 6 ml of saline is added to adjust the volume to atotal of 10 ml. FIG. 4C illustrates the connection to an extension setof the syringe containing the appropriate, pH-adjusted andweight-adjusted dose in a convenient volume, ready for infusionaccording to methods of the present invention;

FIGS. 5A-5D illustrate exemplary embodiments in which dipyridamole andadenosine are administered concurrently according to embodiments of thepresent invention, using a prefilled unit dose syringe of adenosinepharmaceutical composition and a unit dose of dipyridamolepharmaceutical composition separately packaged in a vial. In FIG. 5A,dipyridamole (4 mg in 1 ml) UDF is added to a prefilled 10-ml syringecontaining 28 mg adenosine in 6 ml volume. FIG. 5B shows an optionaladdition of saline to a final volume of 10 ml to facilitateadministration via programmable delivery device, such as an electricpump. In FIG. 5C, the dose is adjusted based on the weight of thepatient, using an exemplary weight graduation scale, e.g., as imprintedon a syringe label, as exemplified in FIGS. 1 and 2. In FIG. 5D, thedosage form so prepared is connected to extension set for infusion; and

FIGS. 6A and 6B illustrate two different exemplary syringe systemembodiments (respectively Model A and Model B) for concurrent infusionof adenosine and dipyridamole according to embodiments of the presentinvention. Models A and B depict examples of interdependent syringes notin fluid communication with one another, optionally provided with labelsfor weight-adjusted dosing on the adenosine-containing syringe.

4. DETAILED DESCRIPTION 4.1. Overview

Although dipyridamole is believed to act indirectly by increasingendogenous adenosine concentration, and in clinical practice has a sideeffect profile similar to that of adenosine, and although dipyridamoleis also known to potentiate exogenous adenosine adverse events to suchan extent that its combination with adjunctively administered adenosineis normally contraindicated (“drugs that augment the effects ofadenosine should be withheld for at least five half-lives prior to theuse of Adenoscan”, quoted from Adenoscan drug label), I have nowdiscovered that extremely low parenteral-subclinical doses ofdipyridamole—on the order of 5% of the dose now used clinically incardiac imaging studies—can potentiate the vasodilation effects ofadjunctively administered adenosine without commensurate potentiation ofadenosine's side effects. This permits adenosine to be used at reduceddosage to effect coronary vasodilation, e.g., for functional assessmentof myocardial function, with equal or superior efficacy as compared tocurrent protocols, yet with reduced side effects, of short duration.

Adenosinergic agents other than, or additional to, adenosine—hereincollectively termed “adenosine receptor agonists”—can be used. Suchagonists are usefully selected from the group consisting of adenosine,and adenosine donors (that is, compounds that can be metabolized toadenosine), including natural donors such as adenosine triphosphate(ATP), adenosine diphosphate (ADP), and adenosine monophosphate (AMP),each at approximately the same dosages as adenosine, and any syntheticmolecule that is capable of being metabolized to adenosine, andpharmaceutically acceptable salts thereof. For convenience of reference,and not by way of limitation, adenosine will typically be described asthe adenosine receptor agonist for use in the methods, compositions, andkits herein.

Agents other than, or additional to, dipyridamole, can likewise beadjunctively administered at sub-maximal dosage to potentiate thedesired coronary vasodilatory effects of the adenosine receptor agonistwith reduced side effects. Such dipyridamole-like agents, hereincollectively termed “adenosine modulators”, interfere with plasmaclearance of adenosine, either by inhibiting or slowing adenosine uptakeby red blood cells and/or endothelial cells, or by inhibiting enzymesinvolved in adenosine anabolic or catabolic metabolism.

For purposes of myocardial perfusion imaging studies, which are of shortduration, preferred adenosine modulators act to reduce or inhibit thecapture of adenosine by erythrocytes and/or endothelial cells. Themodulators may act, e.g., through competition with, or noncompetitiveinhibition of, cell-membrane transporters.

Adenosine modulators useful in the present invention include, inaddition to dipyridamole, hexobendine, dilazep, lidoflazine, draflazine,nitrobenzylthioinosine (NBMPR), nitrobenzylthioguanosine,p-nitronezylthioguanosine (NBTGR), and adenosine analogues such asadenosine-5′-carboxamides and xylosyladenosine, and pharmaceuticallyacceptable salts and derivatives thereof. Other adenosine modulatorsuseful in the present methods include cilostazol, a quinolonederivative, acadesine and papaverine, and pharmaceutically acceptablesalts and derivatives thereof. These latter agents, in addition to theirestablished phosphodiesterase inhibitory activity, are also thought tobe nucleoside transporter inhibitors. Some of the adenosine modulatorslisted above are currently available clinically, in the U.S. and/orEurope, such as cilostazol, papaverine, dilazep, and draflazine,generally in the form of pills for oral administration, some alsoformulated for injection (e.g., papaverine). Other adenosine modulatorsinhibit metabolic enzymes, such as adenosine kinase (which convertsadenosine into AMP) or adenosine deaminase (which converts adenosineinto inosine).

For convenience of reference, and not by way of limitation, dipyridamolewill typically be described as the adenosine modulator for use in themethods, compositions, and kits herein. When dipyridamole is theadenosine modulator and adenosine is the adenosine receptor agonist, thecombination—at any dose ratio—will be referred to herein as Adenosoft.

Example 1, hereinbelow, compares the hemodynamic effects ofadministering dipyridamole and adenosine intravenously as a combined(sequentially administered) pharmacological stressor, to the effects ofadministering adenosine alone in 40 consecutive patients suffering fromischemic heart disease. Each patient served as his own control.Dipyridamole was administered as an intravenous bolus. Adenosine wasadministered immediately thereafter by continuous intravenous infusionfor three minutes. Each of the two agents was administered at a dosagelower than its clinically preferred dosage when used as a single agentfor myocardial perfusion imaging: dipyridamole at 4-6% of itssingle-agent total dose, adenosine at one half its single-agent dosagerate.

Effects were measured using noninvasive transthoracic dopplerechocardiography (TTDE). The measured blood flow velocities (known toreflect coronary blood flow values), whether peak or mean, were 1.5 to4% lower in absolute values than those measured upon administration ofadenosine alone at its standard dosage rate. However, these differenceswere not statistically significant (p>0.05): there was no statisticaldifference between the current standard treatment—infusion of adenosinealone at 140 μg/kg/min—and sequential bolus administration ofdipyridamole at 4-6% of its typical single-agent total dose followed byadenosine infusion at 70 μg/kg/min.

In addition to this series of 40 patients, three (3) patients (excludedfrom the statistical analysis) received the adenosine infusion twominutes after the dipyridamole bolus, rather than immediatelythereafter, and two (2) patients (also excluded from the statisticalanalysis) were injected with the two agents concurrently in the sameinfusion line using a Y-shaped, or Y-, connector. No differences wereseen as compared to the sequential administration protocol.

A significant reduction was seen in the incidence of chest pain amongthe 40 patients in this study, as compared to the number reporting chestpain upon administration of adenosine alone at 140 μg/kg/min. Inaddition, the severity of the three main adverse side effects—chestpain, dyspnea, and flushing—cumulated across all dipyridamole doses, wasreduced by 31.6% with the sequential combination as compared to standardadenosine treatment. This decrease was statistically significant(p=0.001).

As reported in detail in Example 2, 56 patients were assessed in asubsequent Phase II study comparing in a single blind, 2-arm cross overprotocol design dipyridamole-adenosine combination administration toadenosine alone (Adenoscan®, Astellas) as the pharmacologic stressor incoronary patients undergoing single photon emission computed tomography(SPECT) imaging studies.

Study results showed that either the sequential or concomitant IVadministration (premixing) of dipyridamole microdoses at 5% the standarddose, with adenosine (Adenoscan) at 50% its maximal dose, during 4minutes were statistically equivalent in terms of efficacy (severityscore comparison, agreement rate for the presence of perfusion defectsand categorical agreement rate) to the reference drug infused during 6minutes: in endpoint terms the combination is noninferior to Adenoscan(p<0.0001).

Significant reduction in both the occurrence and the severity of chestpain with the dipyridamole-adenosine combination, as compared toadenosine alone, was observed, as was reduction in ST changes on EKG.The occurrence of chest pain (A1 side effect) was significantly reducedby 43% (p=0.03) and severity by 61% (p=0.001). The occurrence of A2 sideeffects with Adenosoft was clearly reduced: by 23% for dyspnea and 24%for flushing. The severity of dyspnea and flushing was reduced by 49%and 51% respectively (p=0.01 and p=0.03). The Adenosoft composite index(cumulative severity of chest pain, dyspnea and flushing) wassignificantly below that of Adenoscan (−53%, p<0.0001).

The data from these first two studies demonstrate (i) that thesequential bolus administration of dipyridamole at 28 to 40 μg/kg—actingas a pretreatment and well below the total dose infused whendipyridamole is used as a single agent stressor—followed by infusion ofadenosine at 70 μg/kg/min (50% less than its usual dosage) over 3minutes, is equally efficacious in providing coronary vasodilation forimaging studies, while causing fewer side effects. The data alsodemonstrate that dipyridamole and adenosine may be combined in a singleinfusion, over 4 minutes, to similar effect. Among the side effectsreduced by the combination of the present invention are chest pain, andthe risk of significant heart blockage.

Two additional studies were conducted in 43 coronary patients assessedfor coronary reserve using transthoracic-doppler-echography. Thesestudies demonstrated that the concurrent administration of adenosine at70 μg/kg/min with dipyridamole at 10 μg/kg/min during a period of onlytwo minutes is statistically equivalent, with respect to efficacy, toadenosine infused at its recommended dose of 140 μg/kg/min. Sideeffects, especially A2a adverse events (dyspnea and flushing), appearedto be further reduced with the 2 minute infusion as compared to thelonger infusion times used in the first two studies. Time to peak toachieve near maximal hyperemia occurs after 1 minute or so of infusionwith adenosine alone (Adenoscan) and after about 1.5 minute with thecombination. Intra-individual measurements showed that in the samepatient return to base line with the combination occurs 10 to 15 secondslater than with adenosine infusion alone. However, time to peak is onaverage close to 1 minute and similar to that of adenosine alone (withunchanged return to baseline), when a fraction of the total dipyridamoledose, acting as a priming dose, in the 0.1-0.3 mg range, is administeredprior to the combination infusion. The same is true when the sequentialadministration mode is used over 2 minutes as was also demonstrated in aseries of 10 consecutive patients (see example 5.5).

These latter data demonstrated that dipyridamole and adenosine may becombined as a single 2 minute infusion with potentially furtherreduction of side effects and maintained efficacy. When infusion time isshortened by one minute and possibly more, efficacy, which very muchdepends on time to peak, can be usefully secured by either: i)administering a priming dose of dipyridamole (actually a fraction ofdipyridamole total dose) administered as pretreatment prior (i.e., lessthan a few seconds and sometimes less than one second) to theadenosine-dipyridamole combination infusion; or ii) by the sequentialadministration mode with dipyridamole (e.g., 40 μg/kg) administeredfirst as a 5-20 seconds bolus rapidly followed by adenosine infusion at70 μg/kg/min over 2 to 3 minutes.

Accordingly, described herein are methods, pharmaceutical compositions,unit dosage forms, and kits that exploit this discovery, combiningadenosine with dipyridamole (or, in various embodiments, other adenosinemodulator) at dosages at which some of the most frequent side effects ofboth adenosine and dipyridamole, notably cardiac side effects, aresignificantly reduced, while maintaining optimal coronary vasodilationfor the diagnosis of myocardial ischemia.

4.2. Methods of Effecting Coronary Vasodilation

In one aspect, methods of effecting coronary vasodilation for cardiacdiagnosis are provided.

In typical embodiments, the methods comprise (i) parenterallyadministering an adenosine modulator, such as dipyridamole, andsequentially thereafter parenterally administering an adenosine receptoragonist, such as adenosine, or (ii) concurrently administering anadenosine modulator, such as dipyridamole, and an adenosine receptoragonist, such as adenosine, optionally with a fraction of the totalmodulator dose administered prior to this concurrent administration.Each of the adenosine modulator, e.g., dipyridamole, and the adenosinereceptor agonist, e.g., adenosine, is administered at a dosage lowerthan that required for maximal coronary vasodilation when the respectiveagent is administered individually by identical parenteral route. Theadenosine modulator and the adenosine receptor agonist are administeredin amounts, at weight ratios, and for a time, sufficient to achieve thedesired therapeutic or diagnostic effect.

Programmable syringe pumps or micropumps, as are typical in clinicalpractice, are usefully employed to facilitate parenteral administrationin precise dosage. However manual administration is also possible wheninfusion time does not exceed 3 minutes.

The route of parenteral administration is chosen based upon the desiredclinical effect, as further described below. In certain embodiments, atleast one of the adenosine modulator, e.g., dipyridamole, and theadenosine receptor agonist, e.g., adenosine, is administered byintravenous infusion. In most embodiments the two active agents areadministered intravenously. In other embodiments, at least one ofdipyridamole and the adenosine receptor agonist is administered byintra-arterial infusion, such as intra-coronary infusion, or byintra-atrial infusion. In these latter embodiments, the active isadministered at a lower rate, and at a lower dosage, than forintravenous infusion, as further described below. In yet otherembodiments, at least one of the actives is administered as a perfusate.

In some embodiments, at least one of dipyridamole and the adenosinereceptor agonist is infused over a period of time of at least 1 minute,typically at least 2 minutes, 3 minutes, 4 minutes, 5 minutes, even atleast 6 minutes. As used herein, “continuous infusion” intends infusionover a period of at least 2 minutes.

In some embodiments, dipyridamole is administered by intravenousinfusion at an infusion rate from 3.5 μg/kg/min to 50 μg/kg/min. Alldosage ranges described herein include the upper and lower recitedlimits, and nonintegral intermediary values. Thus, in some embodiments,dipyridamole is infused at a rate of at least about 3.5 μg/kg/min, atleast about 4 μg/kg/min, at least about 5 μg/kg/min, at least about 6μg/kg/min, at least about 7 μg/kg/min, at least about 7.5 μg/kg/min, atleast about 8 μg/kg/min, at least about 8.75 μg/kg/min, at least about 9μg/kg/min, at least about 10 μg/kg/min, at least about 11 μg/kg/min, atleast about 11.25 μg/kg/min, at least about 12 μg/kg/min, at least about12.5 μg/kg/min, at least about 13 μg/kg/min, at least about 13.75μg/kg/min, at least about 14 μg/kg/min, at least about 15 μg/kg/min, atleast about 16 μg/kg/min, at least about 16.25 μg/kg/min, at least about17 μg/kg/min, and at least about 17.5 μg/kg/min, at least about 18μg/kg/min, at least about 19 μg/kg/min, at least about 20 μg/kg/min, atleast about 21 μg/kg/min, at least about 22 μg/kg/min, at least about 23μg/kg/min, at least about 24 μg/kg/min, at least about 25 μg/kg/min, atleast about 26 μg/kg/min, at least about 27 μg/kg/min, at least about 28μg/kg/min, at least about 29 μg/kg/min, at least about 30 μg/kg/min, atleast about 31 μg/kg/min, at least about 32 μg/kg/min, at least about 33μg/kg/min, at least about 34 μg/kg/min, at least about 35 μg/kg/min, atleast about 36 μg/kg/min, at least about 37 μg/kg/min, at least about 38μg/kg/min, at least about 39 μg/kg/min, at least about 40 μg/kg/min, atleast about 41 μg/kg/min, at least about 42 μg/kg/min, at least about 43μg/kg/min, at least about 44 μg/kg/min, at least about 45 μg/kg/min, atleast about 46 μg/kg/min, at least about 47 μg/kg/min, at least about 48μg/kg/min, at least about 49 μg/kg/min, at least about 50 μg/kg/min,with intermediate values permissible.

In some embodiments, dipyridamole is infused intravenously at a rate ofno more than about 50 μg/kg/min, no more than about 49 μg/kg/min, nomore than about 48 μg/kg/min, no more than about 47 μg/kg/min, no morethan 46 μg/kg/min, no more than about 45 μg/kg/min, no more than about44 μg/kg/min, no more than about 43 μg/kg/min, no more than about 42μg/kg/min, no more than about 41 μg/kg/min, no more than about 40μg/kg/min, no more than about 39 μg/kg/min, no more than about 38μg/kg/min, no more than about 37 μg/kg/min, no more than about 36μg/kg/min, no more than about 35 μg/kg/min, no more than about 34μg/kg/min, no more than about 33 μg/kg/min, no more than about 32μg/kg/min, no more than about 31 μg/kg/min, no more than about 30μg/kg/min, of no more than about 29 μg/kg/min, no more than about 28μg/kg/min, no more than about 27 μg/kg/min, no more than about 26μg/kg/min, no more than about 25 μg/kg/min, no more than about 24μg/kg/min, no more than about 23 μg/kg/min, no more than about 22μg/kg/min, no more than about 21 μg/kg/min, no more than about 20μg/kg/min, no more than about 19 μg/kg/min, no more than about 18μg/kg/min, no more than about 17.5 μg/kg/min, no more than about 17μg/kg/min, no more than about 16.25 μg/kg/min, no more than about 16μg/kg/min, no more than about 15 μg/kg/min, no more than about 14μg/kg/min, no more than about 13.75 μg/kg/min, no more than about 13μg/kg/min, no more than about 12.5 μg/kg/min, no more than about 12μg/kg/min, no more than about 11.25 μg/kg/min, no more than about 11μg/kg/min, no more than about 10 μg/kg/min, no more than about 9μg/kg/min, no more than about 8.75 μg/kg/min, no more than about 8μg/kg/min, no more than about 7.5 μg/kg/min, no more than about 7μg/kg/min, no more than about 6 μg/kg/min, no more than about 5μg/kg/min, no more than about 4 μg/kg/min, no more than about 3.5μg/kg/min, with intermediate values permissible.

In some embodiments, dipyridamole is administered as a bolus, typicallyover a period of about 5-30 seconds.

In some of these embodiments, dipyridamole is administered as anintravenous bolus. In such embodiments, dipyridamole is administered ata dosage between 14 μg/kg to 140 μg/kg. In various embodiments,dipyridamole is administered intravenously as a bolus at a dosagebetween 28 μg/kg and 40 μg/kg, 40 μg/kg being the preferred dosage.

Thus, in certain embodiments, dipyridamole is administered as anintravenous bolus at a dose of at least about 14 μg/kg, at least about20 μg/kg, at least about 25 μg/kg, at least about 28 μg/kg, at leastabout 29 μg/kg, at least about 30 μg/kg, at least about 31 μg/kg, atleast about 32 μg/kg, at least about 33 μg/kg, at least about 34 μg/kg,at least about 35 μg/kg, at least about 36 μg/kg, at least about 37μg/kg, at least about 38 μg/kg, at least about 39 μg/kg, at least about40 μg/kg, at least about 45 μg/kg, at least about 50 μg/kg, at leastabout 55 μg/kg, at least about 60 μg/kg, at least about 65 μg/kg, evenat least about 70, 80, 90, 100, 110, 120, 130, even 140 μg/kg, withintermediate doses permissible.

In some embodiments, dipyridamole is administered intravenously as abolus at a dosage of no more than about 140 μg/kg, 130 μg/kg, 120 μg/kg,110 μg/kg, 100 μg/kg, 90 μg/kg, 80 μg/kg, 70 μg/kg, even no more thanabout 60 μg/kg, even no more than about 55 μg/kg, no more than about 50μg/kg, no more than about 45 μg/kg, no more than about 40 μg/kg, no morethan about 39 μg/kg, no more than about 38 μg/kg, no more than about 37μg/kg, no more than about 36 μg/kg, no more than about 35 μg/kg, no morethan about 34 μg/kg, no more than about 33 μg/kg, no more than about 32μg/kg, no more than about 31 μg/kg, no more than about 30 μg/kg, no morethan about 29 μg/kg, no more than about 28 μg/kg, no more than about 25μg/kg/, no more than about 20 μg/kg/, no more than about 14 μg/kg, withintermediate values permissible.

When administered to a human being, the dosages of dipyridamole usefulin the methods of the present invention can be expressed in μg bymultiplying the dosage, expressed as μg/kg, by the weight of theindividual. For example, for a human weighing 50 kg, the dosage ofdipyridamole useful in the present methods can be expressed as rangingbetween 700 to 7,000 μg; for a human being weighing 60 kg, the dosage ofdipyridamole can be expressed as ranging between 840 to 8,400 μg; for ahuman being weighing 75 kg, the dosage of dipyridamole can be expressedas ranging between 1,050 to 10, 500 μg; and for a human being weighing100 kg, the dosage can be expressed as ranging between 1,400 to 14,000μg.

In various embodiments, dipyridamole is infused intra-arterially at aninfusion rate of no more than about 0.07 μg/kg/min, no more than about0.06 μg/kg/min, no more than about 0.05 μg/kg/min, no more than about0.04 μg/kg/min, no more than about 0.03 μg/kg/min, no more than about0.02 μg/kg/min, or no more than about 0.01 μg/kg/min, with intermediatevalues permissible.

In various embodiments, the adenosine receptor agonist is selected fromthe group consisting of adenosine, and adenosine donors (that is,compounds that can be metabolized to adenosine), including naturaldonors such as adenosine triphosphate (ATP), adenosine diphosphate(ADP), and adenosine monophosphate (AMP), each at approximately the samedosages as adenosine, and any synthetic molecule that is capable ofbeing metabolized to adenosine, and pharmaceutically acceptable saltsthereof.

Typically, adenosine is used. For convenience, its particular use willhereafter be described, without intending thereby to limit the describedmethods to use of adenosine as the adenosine receptor agonist.

In some embodiments, adenosine is administered by intravenous infusionat an infusion rate between 35 μg/kg/min to 100 μg/kg/min. Thus, in someembodiments, adenosine is infused at a rate of at least about 35μg/kg/min, at least about 40 μg/kg/min, at least about 45 μg/kg/min, atleast about 50 μg/kg/min, at least about 55 μg/kg/min, at least about 60μg/kg/min, at least about 65 μg/kg/min, at least about 70 μg/kg/min, atleast about 75 μg/kg/min, at least about 80 μg/kg/min, at least about 85μg/kg/min, at least about 90 μg/kg/min, at least about 95 μg/kg/min, andat least about 100 μg/kg/min, with intermediate values permissible.

In various embodiments, adenosine is infused intravenously at a rate ofno more than about 100 μg/kg/min, no more than about 95 μg/kg/min, nomore than about 90 μg/kg/min, no more than about 85 μg/kg/min, no morethan about 80 μg/kg/min, no more than about 75 μg/kg/min, no more thanabout 70 μg/kg/min, no more than about 65 μg/kg/min, no more than about60 μg/kg/min, no more than about 55 μg/kg/min, no more than about 50μg/kg/min, no more than about 45 μg/kg/min, no more than about 40μg/kg/min, no more than about 35 μg/kg/min, with intermediate valuespermissible.

When administered to a human being, the dosage rate of adenosine can beexpressed in μg/min by multiplying the dosage rate expressed inμg/kg/min by the weight of the individual. For example, for a humanbeing weighing 50 kg, the dosage of adenosine useful in the practice ofthe present methods can be expressed as ranging between 1,750 to 5,000μg/min; for a human being weighing 60 kg, the dosage rate of adenosinecan be expressed as ranging between 2,100 to 6,000 μg/min; for a humanbeing weighing 75 kg, the dosage of adenosine can be expressed asranging between 2,625 to 7,500 μg/min; and for a human being weighing100 kg, the dosage of adenosine can be expressed as ranging between3,500 to 10,000 μg/min.

In some embodiments, adenosine is administered by intra-arterialinfusion, such as intracoronary infusion, at an infusion rate about 200-to 400-fold lower than intravenous infusion. Thus, in some embodiments,adenosine is infused at a rate of at least about 0.50 μg/kg/min, atleast about 0.45 μg/kg/min, at least about 0.40 μg/kg/min, 0.35μg/kg/min, at least about 0.30 μg/kg/min, at least about 0.25 μg/kg/minat least about 0.20 μg/kg/min, at least about 0.15 μg/kg/min, at leastabout 0.10 μg/kg/min, with intermediate values permissible.

In various embodiments, adenosine is infused intra-arterially and inparticular by intracoronary infusion, at an infusion rate of no morethan about 0.10 μg/kg/min, no more than about 0.15 μg/kg/min, no morethan about 0.20 μg/kg/min, no more than about 0.25 μg/kg/min, no morethan about 0.30 μg/kg/min, no more than about 0.35 μg/kg/min, no morethan about 0.40 μg/kg/min, no more than about 0.45 μg/kg/min, even nomore than about 0.50 μg/kg/min, with intermediate values permissible.

In various embodiments, the methods presented herein compriseparenterally administering dipyridamole and sequentially thereafterparenterally administering an adenosine receptor agonist, such asadenosine at an adenosine:dipyridamole (A:D) weight ratio of about 2:1to about 10:1. In other embodiments, the methods comprise concurrentlyadministering adenosine and dipyridamole, without or with a dipyridamolepriming dose at adenosine:dipyridamole weight ratio of about 2:1 toabout 10:1.

In some embodiments, the, ratio is about2:1,3:1,4:1,5:1,6:1,7:1,8:1,9:1, even 10:1, with nonintegral ratiosbetween about 2:1 and about 10:1 permissible. In certain embodiments,the methods comprise concurrent infusion of adenosine and dipyridamole,with or without pre-treatment by a priming dose of dipyridamole or thesequential administration of the two drugs, at an A:D ratio of about 6:1to 8:1, preferably about 7:1. For certain methods further describedbelow, embodiments usefully comprise concurrent or sequential parenteralinfusion of adenosine and dipyridamole at an A:D weight ratio of about2:1 to 4:1.

In various embodiments the sequential method is used: dipyridamole isadministered first as an intravenous bolus, and adenosine isadministered thereafter as an intravenous infusion. In some embodiments,adenosine is administered into a coronary artery at a dose of about 10to about 20 μg/min, regardless of patient weight, after intravenousbolus injection of dipyridamole at a dose of about 20 to about 40 μg/kg,preferably 40 μg/kg.

In certain such embodiments, dipyridamole is administered over about5-30 seconds, and adenosine is thereafter infused for about 1 to 6minutes.

In these embodiments, the total dose of dipyridamole given intravenouslyas a bolus is typically between about 1/16 to about 1/24, e.g., about1/20 (5%), that of the total recommended standard dose when dipyridamoleis used as a single agent (standard single agent dose: 0.56 mg-0.80mg/kg). In these embodiments, the total dose of intravenously infusedadenosine is typically about 25% to about 50% that of the totalrecommended standard dose when adenosine is used as a single agent(standard single agent dose: 0.84 mg/kg).

In certain embodiments, dipyridamole is administered as an IV bolus overabout 5-30 seconds at a dosage of about 14 to 60 μg/kg, followedimmediately (that is, as soon as clinically practicable, typicallywithin about 5 to 30 seconds) by the infusion of adenosine at a dosageof about 35 to 100 μg/kg/min for a period of about 1 to 6 minutes. Theduration of adenosine administration is determined by the chosen imagingmethodology, as is well known in the art.

In some embodiments, an intravenous dipyridamole bolus of 28-40 μg/kg isfollowed immediately—that is, as soon as clinically practicable,typically within about 5 to 30 seconds—by intravenous infusion ofadenosine at 50-70 μg/kg/min for 1 to 4 minutes. In certain embodiments,an IV dipyridamole bolus of 40 μg/kg is followed immediately byintravenous administration of adenosine at 70 μg/kg/min for 3 or 4minutes. In some embodiments, the adenosine administration is for aperiod of about 1 or 2 minutes.

In sequential administration embodiments, adenosine infusion may bedelayed as long as about 2-10 minutes after dipyridamole bolus,typically no more than about 5 minutes after dipyridamole bolus.

In sequential administration embodiments, dipyridamole may be injectedmanually as a bolus via a syringe, or automated by the use of aprogrammable device (e.g., by micropump). When administered bymicropump, dipyridamole may be injected over about 1 to about 2 minutesprior to adenosine infusion. Adenosine infusion is typicallyaccomplished using a programmable device so as to ensure its measureddelivery. However, manual administration over about 2 to about 3 minutesmay also be preformed.

In some embodiments, dipyridamole and adenosine are administeredconcurrently (see, e.g., FIGS. 4 to 6) over about 1 to about 6 minutes.The duration of intravenous administration is determined by the chosenimaging methodology, as is well known in the art. In some embodimentsthe duration can be of either about 3 or about 4 minutes. In otherembodiments of either about 1 or about 2 minutes.

In certain administration embodiments, dipyridamole and adenosine arecombined from separate unit dosage forms and then administeredconcurrently as a single composition.

For example, in some embodiments, a volume of dipyridamole correspondingto a dosage of 14 to 60 μg/kg is sampled and a volume of adenosinecorresponding to a dosage of 35 to 100 μg/kg/min is similarly sampledand the two mixed in the same syringe. In some embodiments, a volume ofdipyridamole corresponding to 28-40 μg/kg is sampled and a volume ofadenosine corresponding to a dosage of 50 to 70 μg/kg/min is similarlysampled, and the two mixed in the same syringe. In certain embodiments,a volume of dipyridamole corresponding to 40 μg/kg is sampled and avolume of adenosine corresponding to a dosage of 70 μg/kg/min issimilarly sampled and the two mixed in the same syringe. Thus, as isdescribed further below, in another aspect, specific unit dosage formsof adenosine are provided, usefully copackaged with specific unit dosageforms of dipyridamole, so as to facilitate the sequential sampling andmixture of both actives in the same syringe. Unit dosage forms can beprefilled syringes (see FIG. 4).

In other embodiments, the total volume of the dipyridamole unit dosageform is injected into the adenosine vial and the two are mixed so thatonly one sampling is required instead of two. Thus, as described below,in another aspect, the invention provides unit dosage forms of adenosinepackaged so as to permit the sterile introduction of an appropriatevolume of dipyridamole. Unit dosage forms of adenosine can also beprefilled syringes (FIG. 5).

In embodiments in which the two actives are combined in a singlecomposition for concurrent administration, the volume to administer isusefully calculated based on the adenosine doses described herein.

In other embodiments, dipyridamole and adenosine are concurrentlyadministered from separate compositions. These separate compositions canbe prefilled syringes. Usefully, the two agents may be introduced intothe same infusion line using a Y connector (at the same dosages as setforth above) or a single connector specifically designed to mix the twoproducts before they reach the venous line (see, e.g., FIG. 6).

In some concurrent administration embodiments, a very low priming doseof dipyridamole is administered prior to the concurrent infusion ofadenosine and dipyridamole at reduced dosages (e.g., Example 4 below).Typically, this priming dose represents a fraction, in the 0.05-0.5 mgrange, of the total dipyridamole dose to be administered into the venousline prior to the combination. It can be injected independently via a Yconnector or administered using the separate administration mode withtwo syringes working in parallel and a specific connector that makes itpossible to automatically deliver the priming dose as soon as concurrentinfusion starts.

4.3. Methods of Pharmacological Stress Testing

Vasodilation that is achieved according to the above-described methodswill often be used as a pharmacological stressor in cardiac stresstests. Accordingly, in certain embodiments, the methods further comprisethe step of assessing cardiac function.

Any method suitable for assessing cardiac function in cardiac stresstesting may be used.

In various embodiments, for example, assessing cardiac function includesuse of one or more techniques selected from the group consisting of:electrocardiography, echography (M mode, two-dimensional, and threedimensional), echo-doppler (in particular transthoracic echo-doppler),cardiac imaging, including planar (conventional) scintigraphy, singlephoton emission computed tomography (SPECT), dynamic single photonemission computed tomography (D-SPECT™ Cardiac Scan), positron emissiontomography (PET), radionuclide angiography (first pass and equilibriumstudies utilizing, e.g., technetium-99 m-labeled red blood cells),nuclear magnetic resonance (NMR) imaging, myocardial perfusion contrastechocardiography, digital subtraction angiography (DSA), x-ray computedtomography (CINE CT) including high speed and ultra high speed CTscanning.

SPECT and PET present certain advantages, not least by providing imagesof the myocardial perfusion status, showing the presence or absence ofreversible defects (ischemia), their location and their severity.

SPECT studies can be performed using any of the isotopes known to besuitable for such studies, such as thallium-201, technetium sestamibi,tetrofosmine. PET studies can be performed using any of the isotopesknown to be suitable for perfusion studies, this including for examplerubidium-82, Copper 62 PTSM[Copper-62-Pyruvaldehyde-bis-(⁴N-thiosemicarbazone)], nitrogen-13(¹³N-ammonia), ¹⁵O-water (H2¹⁵0 Water), fluorine-18 (such as¹⁸F-fluorodihydrorotenone or fluoromisonidazole) but also metabolicmyocardial imaging studies with ¹⁸Fluorine-2-Deoxyglucose, carbon-11(such as 1-[¹¹C] acetate, or C-11 palmitate), Nicotinic acidderivatives, Other isotopes are possible such as boron-11 etc.

Typically, isotope is injected during the infusion of adenosine, andimaging begins after the end of the infusion. In some embodiments, theisotope is administered no less than about 2 minutes after adenosineinfusion has begun.

Echodoppler usefully presents a different advantage over SPECT and PET.It permits a fast and easy hemodynamic assessment of the coronaryreserve for a specific coronary artery, which is another way to evaluatemyocardial perfusion status. Myocardial perfusion contrast echography(Real-time MCE) avoids the use of isotopes and exposure to radiation.These techniques may include parenteral administration of an agentdetectable by ultrasound techniques such as, but not only, hydrophobicdrugs and/or polymers (e.g polyethylene glycol), in the form ofmicrospheres or nanospheres and/or microbubbles made of gas includingair or compositions comprising combinations of these agents (e.g.perflubutane polymers).

Ultra high speed CT scanners, such as the Somatom Definition Flash bySiemens, can scan the chest in less than one second. The technology notonly reduces radiation exposure, but also facilitates the exploration ofthe beating heart without the requirement that the patient hold his orher breath during the exam. High speed and ultra high speed CT scans canbe performed repeatedly at baseline and under stressed conditions forMPI studies.

In other embodiments, cardiac function, such as myocardial perfusion, isassessed using ultrasound detection of ultrasound contrast agents, suchas ultrasound contrast agents with controlled fragility, as described inU.S. Pat. Nos. 6,776,761 and 6,193,951, the disclosures of which areincorporated herein by reference in their entireties.

4.4. Pharmaceutical Compositions

In one aspect, pharmaceutical compositions that are useful in theabove-described methods are provided.

In typical embodiments, the pharmaceutical composition comprisesadenosine and dipyridamole in an adenosine:dipyridamole (A:D) weightratio of about 2:1 to about 10:1, with intermediate (includingnonintegral) values permissible. In certain embodiments in whichadenosine is intended to be administered at 70 μg/kg/min, the ratio isusefully about 7:1, 8:1, 9:1 and 10:1, with intermediate and nonintegralratios permissible. In other embodiments, in which adenosine is to beadministered at 50 μg/kg/min or less, A:D ratios are usefully about 2:1,3:1, and 4:1, with intermediate and nonintegral ratios between 2:1 and4:1 permissible. For certain clinical methods, the composition usefullycomprises adenosine and dipyridamole at an A:D weight ratio of about7:1.

In certain embodiments, the composition has a pH of less than about 4,such as less than about 3.9, 3.8, 3.7, 3.6, 3.5, 3.4, 3.3, even lessthan about 3.2.

In certain embodiments, the pharmaceutical composition is suitable forintravenous, intra-atrial, or intra-arterial infusion.

The composition may, for example, be in the form of a sterile,nonpyrogenic, fluid composition.

In typical fluid embodiments, the concentration of adenosine is at leastabout 1 mg/ml, 2 mg/ml, 3 mg/ml, 4 mg/ml and possibly 5 mg/ml, withintermediate, nonintegral, values permissible. These embodimentstypically have a pH of about 3.5 to about 8. In other typical fluidembodiments with readily a lower pH (e.g., pH 2-3.5), adenosineconcentration can be higher, even at least about 5 mg/ml, 6 mg/ml, 7mg/ml, 8 mg/ml, 9 mg/ml and even 10 mg/ml, with intermediate,nonintegral, values permissible. In typical pharmaceutical compositionembodiments, adenosine is present at a concentration of about 3 mg/ml, 4mg/ml, 5 mg/ml, or 7 mg/ml.

In various fluid embodiments, the concentration of dipyridamole is atleast about 0.1 mg/ml, and may usefully be as high as 4 mg/ml. Theconcentration may, in certain embodiments, be at least about 0.1 mg/ml,0.2 mg/ml, 0.3 mg/ml, 0.4 mg/ml, 0.5 mg/ml, 0.6 mg/ml, 0.7 mg/ml, 0.8mg/ml, 0.9 mg/ml, 1 mg/ml, or more, including, e.g., 1.1 mg/ml, 1.2mg/ml, 1.3 mg/ml, 1.4 mg/ml, 1.5 mg/ml, 1.6 mg/ml, 1.7 mg/ml, 1.8 mg/ml,1.9 mg/ml, 2 mg/ml, 2.1 mg/ml, 2.2 mg/ml, 2.3 mg/ml, or 2.4 mg/ml, 2.5mg/ml, 3 mg/ml, 3.5 mg/ml, 4 mg/ml, with intermediate and nonintegralvalues permissible (e.g., 0.43, 0.57, 0.71, 0.86 mg/ml).

In certain embodiments, the composition comprises adenosine at aconcentration of about 3 mg/ml, and dipyridamole at a concentration ofabout 0.375-0.428 mg/ml (A:D ratios of 8:1 and 7:1), which may berounded to 0.38-0.43 mg/ml. In one embodiment, for example, thecomposition comprises adenosine at a concentration of about 3 mg/ml anddipyridamole at a concentration of about 0.43 mg/ml (ratio 7:1). Inanother embodiment, the composition comprises adenosine at aconcentration of about 4 mg/ml and dipyridamole at a concentration ofabout 0.5-0.57 mg/ml (ratios of about 8:1 to 7:1). In anotherembodiment, the composition comprises adenosine at a concentration ofabout 5 mg/ml and dipyridamole at a concentration of about 0.62-0.71mg/ml (ratios of 8:1 and 7:1). In another embodiment the compositioncomprises adenosine at a concentration of about 6 mg/ml and dipyridamoleat a concentration of about 0.86 mg/ml (ratio 7:1). In anotherembodiment, the composition comprises adenosine at a concentration ofabout 7 mg/ml and dipyridamole at a concentration of about 1 mg/ml(ratio 7:1), and so on, up to adenosine concentrations as high as 10mg/ml.

In some embodiments, the composition is dry, and suitable forreconstitution prior to infusion by addition of a sterile fluid intowhich both dipyridamole and adenosine are readily solubilized. Usefully,the composition comprises adenosine and dipyridamole in amounts suitableto permit reconstitution in the enclosing vessel to the adenosine anddipyridamole concentrations above-described.

Whether fluid or dry, the pharmaceutical composition may furthercomprise carriers and excipients suitable for intravenous, intra-atrial,or intra-arterial administration, as are well known in the art. Amongsuch excipients are those used in currently approved dipyridamole andadenosine compositions, such as tartaric acid, hydrochloric acid andpolyethylene glycol (macrogol 600). Others are permissible, such as, forexample, mannitol. See, http://www.adenosin.com/en/en_SPC_(—)05.pdf(Item Development AB, 2005), incorporated herein by reference. See also,Remington: The Science and Practice of Pharmacy, 21^(st) ed. (2005),Lippincott Williams & Wilkins (ISBN: 0781746736), incorporated herein byreference.

The compositions may further comprise additional actives, and in someembodiments, may further comprise contrast agents, including ultrasoundand MRI contrast agents.

In embodiments intended for continuous intravenous infusion in themethods above-described, adenosine is typically present in thepharmaceutical composition at a concentration, or in a weight amount,that permits adenosine to be infused at a rate between about 35μg/kg/min to about 100 μg/kg/min.

In some of these embodiments, adenosine is present in an amount thatpermits infusion at a rate of at least about 35 μg/kg/min, at leastabout 40 μg/kg/min, at least about 45 μg/kg/min, at least about 50μg/kg/min, at least about 55 μg/kg/min, at least about 60 μg/kg/min, atleast about 65 μg/kg/min, at least about 70 μg/kg/min, at least about 75μg/kg/min, at least about 80 μg/kg/min, at least about 85 μg/kg/min, atleast about 90 μg/kg/min, at least about 95 μg/kg/min, and at leastabout 100 μg/kg/min, with intermediate and nonintegral valuespermissible.

In some embodiments, adenosine is present in the composition in anamount that permits infusion at a rate of no more than about 100μg/kg/min, no more than about 95 μg/kg/min, no more than about 90μg/kg/min, no more than about 85 μg/kg/min, no more than about 80μg/kg/min, no more than about 75 μg/kg/min, no more than about 70μg/kg/min, no more than about 65 μg/kg/min, no more than about 60μg/kg/min, no more than about 55 μg/kg/min, no more than about 50μg/kg/min, no more than about 45 μg/kg/min, no more than about 40μg/kg/min, no more than about 35 μg/kg/min, with intermediate andnonintegral values permissible.

In embodiments intended for continuous intravenous infusion,dipyridamole is typically present in the pharmaceutical composition at aconcentration, or in a weight amount, that permits dipyridamole to beinfused at a rate between about 3.5 μg/kg/min to 50 μg/kg/min.

In some of these embodiments, dipyridamole is present in an amount thatpermits infusion at a rate of at least about 3.5 μg/kg/min, at leastabout 4 μg/kg/min, at least about 5 μg/kg/min, at least about 6μg/kg/min, at least about 7 μg/kg/min, at least about 7.5 μg/kg/min, atleast about 8 μg/kg/min, at least about 8.75 μg/kg/min, at least about 9μg/kg/min, at least about 9.25 μg/kg/min, at least about 9.50 μg/kg/minat least about 10 μg/kg/min, at least about 11 μg/kg/min, at least about11.25 μg/kg/min, at least about 12 μg/kg/min, at least about 12.5μg/kg/min, at least about 13 μg/kg/min, at least about 13.75 μg/kg/min,at least about 14 μg/kg/min, at least about 15 μg/kg/min, at least about16 μg/kg/min, at least about 16.25 μg/kg/min, at least about 17μg/kg/min, and at least about 17.5 μg/kg/min, at least about 18μg/kg/min, at least about 19 μg/kg/min, at least about 20 μg/kg/min, atleast about 21 μg/kg/min, at least about 22 μg/kg/min, at least about 23μg/kg/min, at least about 24 μg/kg/min, at least about 25 μg/kg/min, atleast about 26 μg/kg/min, at least about 27 μg/kg/min, at least about 28μg/kg/min, at least about 29 μg/kg/min, at least about 30 μg/kg/min, atleast about 31 μg/kg/min, at least about 32 μg/kg/min, at least about 33μg/kg/min, at least about 34 μg/kg/min, at least about 35 μg/kg/min, atleast about 36 μg/kg/min, at least about 37 μg/kg/min, at least about 38μg/kg/min, at least about 39 μg/kg/min, at least about 40 μg/kg/min, atleast about 41 μg/kg/min, at least about 42 μg/kg/min, at least about 43μg/kg/min, at least about 44 μg/kg/min, at least about 45 μg/kg/min, atleast about 46 μg/kg/min, at least about 47 μg/kg/min, at least about 48μg/kg/min, at least about 49 μg/kg/min, at least about 50 μg/kg/min,with intermediate and nonintegral values permissible.

In some embodiments, dipyridamole is present in the composition in anamount that permits intravenous infusion at a rate of no more than about50 μg/kg/min, no more than about 49 μg/kg/min, no more than about 48μg/kg/min, no more than about 47 μg/kg/min, no more than about 45μg/kg/min, no more than about 44 μg/kg/min, no more than about 43μg/kg/min, no more than about 42 μg/kg/min, no more than about 41μg/kg/min, no more than about 40 μg/kg/min, no more than about 39μg/kg/min, no more than about 38 μg/kg/min, no more than about 37μg/kg/min, no more than about 36 μg/kg/min, no more than about 35μg/kg/min, no more than about 34 μg/kg/min, no more than about 33μg/kg/min, no more than about 32 μg/kg/min, no more than about 31μg/kg/min, no more than about 30 μg/kg/min, of no more than about 29μg/kg/min, no more than about 28 μg/kg/min, no more than about 27μg/kg/min, no more than about 26 μg/kg/min, no more than about 25μg/kg/min, no more than about 24 μg/kg/min, no more than about 23μg/kg/min, no more than about 22 μg/kg/min, no more than about 21μg/kg/min, no more than about 20 μg/kg/min, no more than about 19μg/kg/min, no more than about 18 μg/kg/min, no more than about 17.5μg/kg/min, no more than about 17 μg/kg/min, no more than about 16.25μg/kg/min, no more than about 16 μg/kg/min, no more than about 15μg/kg/min, no more than about 14 μg/kg/min, no more than about 13.75μg/kg/min, no more than about 13 μg/kg/min, no more than about 12.5μg/kg/min, no more than about 12 μg/kg/min, no more than about 11.25μg/kg/min, no more than about 11 μg/kg/min, no more than about 10μg/kg/min, no more than about 9.25 μg/kg/min, no more than about 9.50μg/kg/min no more than about 9 μg/kg/min, no more than about 8.75μg/kg/min, no more than about 8 μg/kg/min, no more than about 7.5μg/kg/min, no more than about 7 μg/kg/min, no more than about 6μg/kg/min, no more than about 5 μg/kg/min, no more than about 4μg/kg/min, no more than about 3.5 μg/kg/min, with intermediate andnonintegral values permissible.

4.5. Unit Dosage Forms

4.5.1. Adenosine:Dipyridamole Combined Compositions

The pharmaceutical compositions described herein are usefully packagedin a unit dosage form adapted for use in the methods described herein.

In some embodiments, the pharmaceutical composition is in the form of aliquid suitable for parenteral infusion and the composition may, forexample, be packaged in volumes ranging from 2 to 50 ml. Convenient unitdosage forms contain 2 to 14 ml, typically 2, 3, 4, 5, 6, 7, 8, or 14ml. Unit dosage forms containing volumes as low as 1 ml, and unit dosageforms containing higher volumes, such as 15 or 20 ml, are also possible.Intermediate and nonintegral volumes are permissible.

Table 1 provides examples of unit dosage form embodiments of theadenosine dipyridamole pharmaceutical compositions herein described.

TABLE 1 Total amount Maximal patient Maximal patient Total amountAdenosine of adenosine weight (in kgs) weight (in kgs) of dipyridamoleconcentration Volume per dosage covered when covered when (A:D ratio7:1) (mg/ml) (ml) unit (mg) infusion time is of 4 mins infusion time isof 3 mins (mg) 3 7 21 75 100 3 14 42 150 200 6 4 7 28 100 4 14 56 200 85 7 35 125 5 6 7 42 150 200 6 7 2 14 50 2 3 21 75 100 3 4 28 100 133 4 535 125 5 6 42 150 200 6 8 56 200 8

Thus, in some embodiments, the unit dosage form usefully contains 14 mgof adenosine and 2 mg of dipyridamole in 2 ml; 21 mg of adenosine and 3mg of dipyridamole in 3 or 7 ml; 28 mg of adenosine and 4 mg ofdipyridamole in 4 or 7 ml; 35 mg of adenosine and 5 mg of dipyridamolein 5 or 7 ml; 42 mg of adenosine and 6 mg of dipyridamole in 6 or 7 or14 ml; 56 mg of adenosine and 8 mg of dipyridamole in 8 or 14 ml.

In some embodiments, the unit dosage forms can be prefilled syringes(see, e.g., FIGS. 4-6). In a variety of embodiments, prefilled syringeshave a total capacity as described above of 5, 10, 15, 20 or even 30 ml,allowing addition of saline to the dose if needed to adjust the pH orprovide an administration volume more readily programmable on anelectric pump or similar automated delivery device. Use of saline may becalled for where the composition has an acidic pH of about 2 to 4.5.

In certain embodiments, the unit dosage forms are vials as described inTable 1 and the pharmaceutical compositions are sampled using emptysyringes of standard size of 5, 10, 15, 20, and even 30 ml totalcapacity.

Whether pre-filled, or to be filled by sampling one or more vials,syringes for use in the methods of the present invention may be usefullylabeled with a weight graduation scale to facilitate weight-adjustmentbefore administration.

Accordingly, in one aspect of the present invention, syringe labels areprovided with weight graduation scales and the corresponding volume of apharmaceutical composition comprising an active to be administered basedon a patient's weight. These labels permit rapid and accuratecalculation of the dose to be administered based on patient weight,reducing the likelihood of a dosing error. Using the labels, dose can bedirectly adjusted according to the patient's weight by moving thesyringe plunger to the appropriate weight on the label affixed to thesyringe barrel. In some embodiments, the unit of weight is a kilogram.In some embodiments, the unit of weight is a pound.

Labels comprise weight graduations for dosing and can be tailored basedon desired infusion time, concentration of active(s) in thepharmaceutical composition, and administration volume. See FIGS. 1 and4. For example, if infusion time is 4 minutes and the composition to beadministered comprises 28 mg adenosine and 4 mg dipyridamole in a 4 mlvolume, a 10-ml prefilled syringe can be labeled with a graduation scalewhere 1 kilogram=0.04 ml. In this embodiment, a 4 ml injection providesthe dose appropriate for a patient weighing 100 kgs, or 4 ml=100 kg.Similarly, in an embodiment where the same composition is provided in avolume of 7 ml as described in Table 1, a prefilled syringe of 15 or 20ml is recommended with a graduation scale where a one kilogram intervalcorresponds to 0.07 ml and 7 ml=100 kg. In one embodiment, where thecomposition comprises 35 mg adenosine with 5 mg dipyridamole in a 7 mlvolume, a prefilled syringe of 15 or 20 ml is used with a graduationscale such as a one kilogram interval is equivalent to 0.056 ml and 7ml=100 kg. Given the present disclosure, one of skill in the art canreadily make labels with appropriate weight and volume graduations forany of the compositions or dosage forms described herein. Scales can beexpressed in any unit that is known to those of skill in the art. Forexample, weight units including, but not limited to, kilograms or poundsmay be used.

As yet another example, if infusion time is 3 minutes, the weightgraduation scale is modified accordingly. For example, labels can beprovided in which kilogram intervals equivalent to ¾ (×0.75) the valueof those described above, or a 1 kilogram interval corresponds to 0.03ml (where the composition comprises 28 mg adenosine and 4 mgdipyridamole in 4 ml) or 0.0525 ml (where the composition comprises 28mg adenosine and 4 mg dipyridamole in 7 ml) or 0.042 ml (where thecomposition comprises 35 mg adenosine and 5 mg dipyridamole in 7 ml).

In some embodiments, the weight graduation scale is in kilograms and thescale can range from 10 or 40 kilograms up to 100 or 125 or 133 or 150or 166 or even 200 kilograms depending on the syringe capacity. In someembodiments, the milliliter per kg equivalence can range typically from0.01 ml=1 kg to 0.2 ml=1 kg depending on the dose, the volume of liquidin the syringe, and the recommended infusion time. In some embodiments,the graduation scale is such that a one kilogram interval can equal 0.03ml, or 0.04 ml or 0.042 ml, or 0.0525 ml, or 0.056 ml, or 0.07 ml,according to needs and the features of the syringe used. In someembodiments, syringes are provided with a weight graduation scale inpounds.

The container for unit dosage embodiments is typically adapted for usewith standard intravenous infusion sets, syringe pumps and adaptedconnectors.

Whether liquid or dry, the unit dosage form is typically sterile andnonpyrogenic.

4.5.2. Dipyridamole Unit Dosage Forms

In typical embodiments of the methods herein described, dipyridamole isadministered at about 5% of the dose at which it is currentlyadministered as a single agent. Accordingly, in one aspect, theinvention provides novel unit dosage forms of dipyridamole.

In some embodiments, dipyridamole unit dosages forms are provided inprefilled syringes. Prefilled syringes of 1 or 2 ml with compositionscomprising dipyridamole at about 2 to about 4 mg/ml and of a lengthsufficient to allow a clear reading of graduation marks allow forimmediate dose adjustment according to patient weight and can be usedwithout predilution in saline despite the acidity of dipyridamole'smedium (pH=2-3.6). In certain embodiments, the final dose can beinjected before adenosine administration directly into a venous line viaa Y connector provided a long enough line (e.g. about 100 cms) filledwith solution to ensure instantaneous dilution of dipyridamole. In thisexample, the recommended ratio of dipyridamole to the buffered solutionis 1:2. In some embodiments, an extension set with an inner volume of atleast 2 ml and possibly 4 ml is provided along with the prefilledsyringe allowing sufficient dipyridamole dilution. In some embodiments,unit dosage forms or prefilled syringes of 3 mg/ml, 4 mg/ml, 6 mg/2 mlor 8 mg/2 ml) are provided.

Dipyridamole unit dosage forms (dipyridamole concentrations of 2 mg/ml,3 mg/ml, 4 mg/ml, 6 mg/2 ml, or 8 mg/2 ml) are also convenient forconcurrent administration with adenosine. In some embodiments, theentire dipyridamole unit dose is mixed into the adenosine unit dose,prior to administration (see FIG. 5). In some embodiments, dipyridamoleis administered concurrently with adenosine using separate syringes withthe each of the two syringes' open ends in fluid communication with, andthe syringe contents flowing into, the same connector, where the twoproducts are mixed before reaching the venous line as a singlecomposition (see FIG. 6).

In various embodiments, a label for synthetic (plastic, resin, polymer,or equivalent) or glass syringes prefilled with 1 or 2 ml ofdipyridamole alone (typically 4 mg/ml) with kilo graduation marks on thebarrel is designed providing 0.01 ml intervals per kilogram (see example7 and FIG. 2A).

Specific dipyridamole unit dosage forms of 1 mg in 1 ml that can beprefilled syringes are particularly useful when a priming dose isinjected into the venous line independently from any other system.

4.5.3. Adenosine Unit Dosage Forms

In some embodiments, dipyridamole and adenosine are sampled fromseparate unit dosage forms, and mixed in the same syringe. In theseembodiments, convenient adenosine unit dosage forms are 14 mg ofadenosine in 7 ml, or 28 mg of adenosine in 7 ml and 56 mg of adenosinein 14 ml (4 mg/ml adenosine) or 21 mg of adenosine in 7 ml and 42 mg ofadenosine in 14 ml (3 mg/ml adenosine). Possibly also 35 mg of adenosinein 15 ml. The syringe employed for sampling can be of standard 10, 15 or20 ml and even 30 ml capacity so as to cope with all syringe pumpsystems and be usefully custom scaled, as above-described, with kilo,pound, or other, weight graduation marks. In certain embodiments, theadenosine unit dosage forms are prefilled syringes.

In some specific embodiments convenient unit dosage forms are 21 mg ofadenosine in 10 ml, or 42 mg in 20 ml (adenosine concentration=2.1mg/ml), 28 mg of adenosine in 10 ml or 56 mg in 20 ml (adenosineconcentration=2.8 mg/ml). Unit dosage forms of 14 mg adenosine in 10 mland 35 mg adenosine in 10 ml are also possible. Unit dosage forms arepreferably prefilled syringes so as to avoid the sampling phase. Inthese embodiments saline may be added after adjustment of the dose intothe syringe to reconstitute 10 or 20 ml prior to infusion if adenosineis infused via an electric pump. However in some cases adenosineprefilled syringes can be administered manually directly into the venousline as a 2 to 3 minute bolus-infusion without addition of saline.

In some embodiments, the unit dosage form comprises a pre-filled syringecomprising 60 mg adenosine in a volume of 20 ml. In some embodiments,the unit dosage form comprises a pre-filled syringe comprising 90 mgadenosine in a volume of 30 ml.

Regardless of their volume, and irrespective of whether prefilled orempty, to be filled by sampling, the syringe barrel in variousembodiments is usefully inscribed with scales with patient weightgraduation marks in order to facilitate dose adjustment. Automatedlabeling systems, e.g., systems using glue to fix and wrap the labelaround the barrel of 5, 10, 15, 20, 30, 40, or 50 ml syringes (as wellas around syringes of non standard capacity), or shrink-wrap labeltechniques are well known industrial procedures by those skilled in theart. In other embodiments, gradations can be molded directly into thebarrel.

Depending on the intended or desired infusion time and the volume ofliquid in the syringe, different labels with different weight graduationscales can be made.

For example, if infusion time is 4 minutes and the composition comprises28 mg of adenosine prefilled in a 10-ml syringe, the graduation scale issimilar to the one shown in FIG. 1 with an interval of 1 kilogram=0.1 mlwherein 10 ml equals 100 kgs, 6 ml=60 kgs, and so on. If the intendedinfusion time is of 3 minutes, the graduation scale will be similar tothe other scale shown in FIG. 1 with an interval of 1 kilogram=0.075 mlwherein 10 ml is equivalent to 133 kgs, 9 ml to 120 kgs, 7.5 ml to 100kg, and so on. If infusion time is of 4 minutes and the composition madeof 35 mg adenosine in 10 ml and prefilled in a syringe of 10 or 15 mlcapacity, the 1 kilogram interval is =0.08 ml. If infusion time is of 3minutes, the kilogram interval is =0.06 ml. For an infusion time of 3minutes, the kilogram interval is equivalent to 0.09 ml when thepreparation is made of 35 mg adenosine in 15 ml and to 0.12 ml when 35mg adenosine are in a 20 ml volume. If the composition comprises 21 mgof adenosine prefilled in a 10-ml syringe and an infusion time of 3minutes is desired, the graduation scale is similar to the one shown inFIG. 2, where 1 kilogram=0.1 ml, and, for example, 6 ml is the dose for60 kgs, and 10 ml is the dose for 100 kgs. If the composition comprises21 mg of adenosine prefilled in a 10 ml syringe and an infusion time of2 minutes is desired, the graduation scale is usefully such that 1kg=0.14 ml, and, for example, 10 ml is the dose for 150 kg.

As described above, in some embodiments, dipyridamole and adenosine areusefully provided in separate pharmaceutical compositions, andadministered sequentially. However in other embodiments there arecombined prior to administration. In some of these embodiments, adipyridamole composition is usefully introduced into a unit dose ofadenosine, and the combined composition then administered.

Thus, unit dosage forms of adenosine are provided, in which adenosine isformulated in sterile fluid composition, and in which the dose packagingpermits sterile introduction of a second fluid in a volume at least 15%that of the adenosine composition (see, e.g., FIG. 5).

Adenosine may be present at any of the concentrations at which it ispresent in the pharmaceutical compositions above-described butpreferably from 1 mg/ml to 5 mg/ml—either as directly packaged, or asthereafter will achieved upon introduction of an appropriate amount ofdipyridamole composition.

For example, in one embodiment, an adenosine unit dosage form contains21 mg adenosine in 6 ml (21 mg/6 ml). This will reconstitute to adesired 21 mg adenosine/7 ml (3 mg/ml adenosine) composition uponintroduction of 1 ml of 3 mg/ml dipyridamole (e.g., the entirety of aunit dose of dipyridamole containing 1 ml dipyridamole at 3 mg/ml). Inanother embodiment, an adenosine unit dosage form contains 42 mg/12 ml.This will reconstitute to a desired 42 mg/14 ml (3 mg/ml) adenosine uponintroduction of a 6 mg/2 ml dipyridamole unit dose. In anotherembodiment, the adenosine unit dosage form contains 28 mg adenosine/6ml, which will reconstitute to 28 mg/7 ml (4 mg/ml adenosine) uponintroduction of a 4 mg/ml dipyridamole unit dose. In another embodiment,the adenosine unit dosage form contains 56 mg adenosine/12 ml, whichwill reconstitute to 56 mg/14 ml (4 mg/ml adenosine) upon introductionof an 8 mg/2 ml dipyridamole unit dose. In another embodiment, theadenosine unit dosage form contains 35 mg adenosine/14 ml, which willreconstitute to 35 mg/15 ml (3 mg/ml adenosine) upon introduction of an5 mg/l ml dipyridamole unit dose. The following Table 2 summarizesexemplary unit dosage forms.

TABLE 2 Maximal patient's Volume (ml) Total weight of amount covered bydipyridamole Final of Total the Initial solution adenosine adenosineamount of composition adenosine Initial added to vial (ml) Final perunit dipyridamole (kgs) when vial adenosine each volume after adenosinedosage (A:D ratio infusion volume concentration adenosine addition ofconcentration form 7:1) time is (ml) (mg/ml) vial dipyridamole (mg/ml)(mg) (mg) 4 mins 3 4.66 1 4 3.5 14 2 50 6 3.5 1 7 3 21 3 75 6 4.66 1 7 428 4 100 12 3.5 2 14 3 42 6 150 12 4.66 2 14 4 56 8 200 14 2.50 1 15 335 5 125

In certain embodiments the total capacity of prefilled syringescomprising unit doses as described in table 2 is of 5, 10, 15, 20 or 30ml, which are standard sizes compatible with various types of electricalpumps and permitting, if necessary, the addition of saline.

In other embodiments dipyridamole and adenosine are concurrently givenfrom separate unit dosage forms or prefilled syringes that deliver thetwo drugs in parallel into the same venous line. In these embodiments,convenient adenosine unit dosage forms are the same as those describedabove.

Typically, dosing and sampling are determined according to adenosinetables.

4.6. Kits

In another aspect, kits are provided in which one or more unit dosageforms of dipyridamole, such as those above-described, are packaged withone or more unit dosage forms of adenosine, such as thoseabove-described. Typically, the kit will comprise an equal number ofdipyridamole doses and adenosine doses.

In some embodiments, the unit dosage of dipyridamole is a prefilledsyringe containing for example 3 mg or 4 mg or 6 mg or 8 mg of activeingredient and the adenosine unit dosage form another prefilled syringewith for example 21 mg or 28 mg or 42 mg or 56 mg of active ingredientso as to respect the preferred 1:7 ratio between the two products.

In certain embodiments these two prefilled syringes, although separated,can share the same plunger (or have these two pieces joined together)and can usefully present two open ends that are in fluid communicationwith, and the contents flowable into, the same connector for the mixingof the two products before they reach the extension set (e.g., venousline).

In some embodiments, the unit dose of dipyridamole is packaged in apre-packed vial, and the adenosine unit dose is packaged as a prefilledsyringe with an injection port, such as a septum, permitting sterileintroduction of dipyridamole into the adenosine dose.

In some embodiments, the unit dosage form is a vial or a prefilledsyringe containing both adenosine and dipyridamole as described above.

In certain embodiments wherein adenosine and dipyridamole areadministered concurrently and preceded by a dipyridamole priming dose, a1 mg in 1 ml dipyridamole prefilled syringe is provided in the kit.

In various embodiments, the kit further includes one or more of anadenosine dosage table, one or more needles, diluent (e.g., saline),appropriate connectors and infusion sets of at least 2 ml in totalvolume, preferably 4 ml.

5. EXAMPLES 5.1. Example 1 Sequential Administration—Assessment of theCoronary Vasodilation Induced by the Combination by TransthoracicDoppler-Echography

The effects of administering sequentially dipyridamole and adenosineintravenously as a pharmacological stressor were compared to the effectsof administering adenosine alone in 40 consecutive patients sufferingfrom ischemic heart disease. In the combined administration, each of thetwo agents was administered at a dosage lower than its clinicallypreferred dosage when used as a single agent for myocardial perfusionimaging. Effects were measured using noninvasive transthoracic dopplerechocardiography (TTDE).

Primary efficacy end-points were peak and mean diastolic flow velocities(measured as reflecting coronary blood flow values). The secondaryend-point was patient tolerance to the procedure. The protocol wasdesigned as follows.

Forty (40) consecutive patients suffering from ischemic heart diseasewere enrolled. Each patient served as his own control.

Adenosine was administered by IV infusion for three minutes at thestandard single-agent infusion rate of 140 μg/kg/min.

After a stabilization period of five minutes, patients then received anIV injection of dipyridamole at a total dose of either 23 μg/kg, 28μg/kg, or 35 μg/kg, administered as a bolus over about 20-30 seconds.Total doses are between about 4-6% of the lowest single-agent total doseof dipyridamole (i.e., 0.56 mg/kg, infused over a total of 4 minutes).Preliminary dose ranging studies at lower doses of dipyridamole (10, 14and 18 μg/kg) showed no effect.

The bolus injection of dipyridamole was followed immediately by an IVinfusion of adenosine at 70 μg/kg/min for 3 minutes. This dose is halfthe standard single-agent dosage rate of 140 μg/kg/min.

Blood flow velocity was measured in the left anterior descendingcoronary artery (LAD) at four time points: (i) before initial adenosineinfusion (spontaneous flow at rest), (ii) during the initial 140μg/kg/min adenosine infusion, (iii) before the sequential administrationof dipyridamole and adenosine (during the stabilization period), and(iv) during the 70 μg/kg/min adenosine infusion, subsequent todipyridamole bolus injection.

Results are given in Tables 3-6. Abbreviations used in the table aredefined below:

ADE: adenosine alone at 140 μg/kg/min

SC: sequential combination of dipyridamole followed by adenosine at 70μg/kg/min

PV: peak velocity (cm/sec)

MV: mean velocity (cm/sec)

max: velocity under stress conditions

min: velocity at rest (under basal conditions)

( ): standard deviation

D %: velocity differential (peak or mean), as percentage of maximum peakor mean velocity

Table 3 presents results comparing dipyridamole 28 μg/kg IV bolus (over20-30 seconds) followed by adenosine infusion at 70 μg/kg/min (“DIP5”sequential combination) as compared to adenosine infusion alone at thestandard single-agent dose of 140 μg/kg/min, in 30 patients.

TABLE 3 Peak Peak Mean Mean velocity velocity velocity velocity ADE SCADE SC Max Min Max Min Max Min Max Min Mean (s.d.) 82.6 30.6 81 30.661.4 23.1 60.2 22.9 (20.7) (8.5) (21) (9.6) (15.1) (6.1) (15.3) (7.3)Max velocity differential PV: 82.6 − 81 = 1.6 MV: 61.4 − 60.2 = 1.2 Maxvelocity differential (D %) 1.9% 1.9% P value 0.217 0.201

Table 4 presents results comparing dipyridamole (35 μg/kg) bolus(administered over 20-30 seconds), followed by adenosine, administeredby infusion at a rate of 70 μg/kg/min (“DIP4” sequential combination) ascompared to adenosine infusion alone at the standard single-agent doseof 140 μg/kg/min, in 5 patients.

TABLE 4 Peak Peak Mean Mean velocity velocity velocity velocity ADE SCADE SC Max Min Max Min Max Min Max Min Mean (s.d.) 80 28 78.8 28 60.422.2 57.8 23 (22.3) (7.4) (15.3) (7.7) (15.5) (5)  (14.4) (5.7) Maxvelocity differential PV: 80 − 78.8 = 1.2 MV: 60.4 − 57.8 = 2.6 Maxvelocity differential 1.5% 4.3% (D %) P value 0.990 0.448

Table 5 presents results comparing dipyridamole (23 μg/kg), administeredas a bolus over 20-30 seconds, followed by adenosine, administered byinfusion at a rate of 70 μg/kg/min (“DIP6” sequential combination) ascompared to adenosine infusion alone at the standard single-agent doseof 140 μg/kg/min, in 5 patients.

TABLE 5 Peak Peak Mean Mean velocity velocity velocity velocity ADE SCADE SC Max Min Max Min Max Min Max Min Mean (s.d.) 107 37.6 105.4 38.680.2 28.2 79.2 30 (36.5) (12.1) (34.3) (16.5) (25.4) (11.1) (24.2)(14.7) Max velocity PV: 107 − 105.4 = 1.6 MV: 80.2 − 79.2 = 1differential Max velocity 1.5% 1.2% differential (D %) P value 0.8750.830

Table 6 presents results cumulated from all 40 patients:

TABLE 6 Peak Peak Mean Mean velocity velocity velocity velocity ADE SCADE SC Max Min Max Min Max Min Max Min Mean (s.d.) 85.3 31.2 83.8 31.363.6 23.7 62.3 23.7 (24)   (9)  (23.3) (10.5) (17.3) (6.8) (17.3) (8.4)Max velocity differential PV: 85.3 − 83.8 = 1.5 MV: 63.6 − 62.3 = 1.3Max velocity differential 1.75% 2% (D %) P value 0.314 0.109

The measured blood flow velocities, whether peak or mean, were 3 to 4%lower, in absolute values, than those of adenosine alone (see Tables 3to 6). However, these differences were not statistically significant(all P values >0.05): there was no statistical difference between thestandard treatment—infusion of adenosine alone at 140 μg/kg/min—andsequential bolus administration of dipyridamole (at 4-6% its typicalsingle-agent total dose) followed by adenosine at 70 μg/kg/min, whetherassessed separately for each of the three tested dipyridamole doses(Tables 3-5), or cumulated across all dipyridamole doses (Table 6).

Tolerance: occurrence and severity of adverse events

Table 7 shows the number and frequency of occurrence among all 40patients of the three adverse events most commonly observed in clinicalpractice upon administration of adenosine alone at 140 μg/kg/min: chestpain, dyspnea, and flushing.

TABLE 7 ADE All SC (DIP 4/5/6) # patients # patients reporting eventsreporting events Adverse event (frequency) (frequency) % reduction Chestpain  9 (22.5%)  5 (12.5%) −44% Dyspnea 20 (50%)   18 (45%)   slightFlushing 21 (52.5%) 17 (42.5%) slight

Table 8. Cumulative results on the severity of the three subjectivesymptoms of the composite (chest pain, dyspnea, flushing) rated from 0to 30. Cumulative results on the severity of the three subjectivesymptoms of the composite (chest pain, dyspnea, flushing) rated from 0to 30.

TABLE 8 Adenosine alone SC DIP4 (n = 5) Chest pain  1.2 ± 2.68 0 ± 0Dyspnea  1.4 ± 1.95  1.2 ± 1.79 Flushing  2.9 ± 2.88  0.8 ± 1.79Composite index  5.5 ± 2.12 2 ± 2 DIP5 (n = 30) Chest pain 1.12 ± 1.95 0.5 ± 1.28 Dyspnea 2.33 ± 2.59 1.87 ± 2.31 Flushing 2.35 ± 2.53 1.82 ±2.35 Composite index  5.8 ± 3.44 4.18 ± 3.39 DIP6 (n = 5) Chest pain 0 ±0 0 ± 0 Dyspnea   5 ± 3.08   3 ± 3.08 Flushing  3.2 ± 3.42  1.4 ± 2.61Composite index  8.2 ± 1.09  4.4 ± 2.41 TOTAL (n = 40) Chest pain 0.99 ±1.93 0.37 ± 1.12 Dyspnea 2.55 ± 2.71 1.92 ± 2.34 Flushing 2.52 ± 2.631.64 ± 2.29 Composite index 6.06 ± 3.17 3.94 ± 3.18

Table 9 presents cumulative statistical results on the severity of thethree subjective symptoms of the composite (chest pain, dyspnea,flushing) rated from 0 to 30.

TABLE 9 Adenosine/ Wilcoxon Adenosine alone dipyridamole signed-ranktest Chest pain 0.99 ± 1.93 0.37 ± 1.12 0.008 Dyspnea 2.55 ± 2.71 1.92 ±2.34 0.02 Flushing 2.52 ± 2.63 1.64 ± 2.29 0.02 Composite index* 6.06 ±3.17 3.94 ± 3.18 <.0001 Composite index = Chest pain + dyspnea +flushing

Chest pain, dyspnea, flushing and the composite index (chest pain,dyspnea and flushing) were less severe in the adenosine/dipyridamoletreatment group than in the Adenosine alone treatment group (p values of0.008, 0.02, 0.02 and <0.0001, respectively).

As shown in Table 7 the number (and frequency) of adverse events relatedto the stimulation of A1 receptors, mainly chest pain, was reduced by44% and its severity (Table 8 and 9) decreased by over 60% with thesequential combination treatment as compared to adenosine alone. Thenumber (and frequency) of adverse events related to the stimulation ofA2a receptors, mainly dyspnea and flushing, did not decrease. Howevertheir severity (not shown) decreased by 24 and 38% respectively, withthe sequential combination compared to adenosine alone.

The mean coronary flow reserve (ratio of maximal-stimulated coronaryblood flow “CBF” to baseline-resting CBF equivalent to peak and meanblood flow velocities ratios) of the 40 patients enrolled in the studywas above 2 (normal value), which indicates that the observed reductionin side effects with sequential treatment was drug dependent, and notflawed by the ischemic status of the studied population.

Although not shown in the tabular data, EKG was not significantlydifferent with the sequential combination treatment as compared tostandard single-agent adenosine, and remained unchanged in all thepatients. Vital signs (heart rate, systolic and diastolic bloodpressures) changed similarly with the two methods. However, the heartrate increase and blood pressures decreases were less pronounced withthe sequential combination than with adenosine alone.

It should be noted that in addition of the first series of 30 patients(DIP5 group), three (3) patients received the adenosine infusion 2minutes after the dipyridamole 28 μg/kg bolus, and two (2) patients wereinjected the two agents (dipyridamole and adenosine) concurrently in thesame infusion line using a “Y” connector using the same dose. These twomodalities appeared equally effective and as effective as the immediatesequential administration protocol.

The results observed and protocol design were validated by twoconsecutive infusions of adenosine given at the standard dose of 140mcg/kg/min and separated by a 5 minute interval: no difference was seen(p>0.05) in velocity measurements between the two infusion whichconfirms the documented fact that adenosine administered acutely andrepetitively does not induce tachyphylaxis.

Results are shown in Table 10. Abbreviations used in the table aredefined below:

PV: peak velocity (cm/sec)

MV: mean velocity (cm/sec)

max: velocity under stress conditions

min: velocity at rest (under basal conditions)

ADE1: first adenosine infusion

ADE2: second adenosine infusion

TABLE 10 PV- PV- MV- ADE1 ADE2 ADE1 MV-ADE2 Patient ID Max Min Max MinMax Min Max Min MART 68 34 60 31 49 25 45 23 LIEN 65 23 66 22 48 17 4816 GRAND 102 30 103 29 75 22 75 22 NGHI 73 30 63 26 53 23 47 21 CORD 7028 62 25 50 20 48 20 Mean 75.6 29 70.8 26.6 55 21.4 52.6 20.4 Max PV:75.6 (ADE1) − MV: 55 (ADE1) − velocity 70.8 (ADE2) = 4.8 52.6 (ADE2) =2.4 differ- ential P value 0.12 0.11

In a second set of control experiments, dipyridamole was administeredalone by bolus injection to 5 patients at the dosage of 28, 35 or 40μg/kg after a three minute adenosine infusion at 140 μg/kg/min, andagain after a 5 minute stabilization period. Data are shown in Table 11.

TABLE 11 DIP PV- PV- MV- Symptoms Symptoms Patient dose ADE DIP ADEMV-DIP under under ID (μg/kg) Max Min Max Min Max Min Max Min ADE DIPalone GROS 28 84 27 26 23 64 20 21 19 Flushing None 8/10 COCH 35 84 3240 30 61 23 28 22 Flushing None 6/10 WURI 35 88 25 23 21 71 21 20 18None None STUR 40 92 33 35 33 67 23 25 23 Dyspnea None 5/10 TALL 40 11233 40 34 86 25 29 24 None None

Dipyridamole alone did not modify peak and mean diastolic velocities. Nosymptoms were recorded during a follow-up of 10 minutes. The datademonstrate that intravenous bolus administration of dipyridamole as asingle agent in the dosage range used in the experimental protocol, hasno detectable effects; doses of dipyridamole at 28 to 40 μg/kg alone donot induce significant hemodynamic and clinical effects and thereforeare subclinical doses.

5.2. Example 2 Sequential and Concurrent Administration of theCombination. Single Photon Emission Computed Tomography (SPECT) ImagingStudy

A Phase II study, now completed, compared dipyridamole-adenosinecombination administration (also termed herein, at all doses,Adenosoft™) to adenosine alone (Adenoscan®, Astellas) as a pharmacologicstressor in coronary patients undergoing single photon emission computedtomography (SPECT) imaging studies. The study was a mono-center,single-blind, 2-arm, cross-over trial.

All patients underwent a first SPECT imaging study using adenosine assingle agent pharmacologic stressor at 140 μg/kg/min, according tostandard clinical protocol. Only those patients in whom an ischemic zonewas detected were declared eligible for the second test, and wereenrolled in the study if other inclusion criteria were satisfied.

In the second test, eligible patients were stressed pharmacologically byeither bolus administration of dipyridamole over 20-30 seconds, followedby adenosine infusion at 70 μg/kg/min or their concurrentadministration. SPECT images were acquired as per the standard approachperformed the preceding week.

Since thallium is currently deemed the best isotope to test myocardialviability at rest, and sestamibi the best isotope to detect myocardialdefects under stress conditions, a dual isotope myocardial scintigraphytechnique was used for this study. The isotope was injected after a 3minute infusion with Adenoscan or after a 2.5 minute infusion with thecombination.

The primary end-point was to show the non inferiority of Adenosoft imagevs. Adenoscan images. The comparison encompassed the strength ofagreement for myocardial defects but also the severity of the reversibledefects induced by the two products using a validated score method.

Randomization of SPECT images, and their analysis by two blindedreaders, took place every 10 patients. Anonymous and randomized imageswere assessed using the standard 17-segment model and thesemi-quantitative visual score method on a 5-point scale (from 0 to 4).An additional totally computerized quantitative method was performedusing the validated CardioGam software (Segami Corp.). All images wereinterpreted and quantified automatically by the software calculationpackage.

Tolerance and safety (secondary end-point) of the procedure was analyzedas in the preceding hemodynamic study (Example 1) using a visual scale,focusing on the three most common symptoms seen with adenosine, as wellas on EKG changes and other usual cardiac parameters.

5.2.1. SPECT Image Analysis and Scoring Method (Semi-QuantitativeAnalysis)

The “summed score” (SS) quantified the myocardial defect(s) in one ormore of the 17 cardiac segments, as scored from 0 to 4 by the blindedreaders using the following scale: normal perfusion=0, mild reduction incounts=1, moderate reduction in counts=2, severe reduction=3, absence ofuptake=4.

Summed stress scores (with Adenosine or with Adenosoft) were defined asSSS, summed rest scores (Thallium) as SRS and summed difference scoresas SDS=SSS-SRS. Delta scores were calculated as the difference betweenthe summed difference scores of Adenoscan and the summed differencescores of the combination (Δ: delta scores=SDS (A)−SDS(C)), reflectingthe difference between ischemia induced by adenosine and thecombination. Ideally the delta scores of the two independent blindreaders had not to differ by more than 2. If >2, images were read againby a third independent expert.

The severity and extent of reversible defects was categorized into mild(SDS 0 to 1), moderate (SDS 2 to 4) and severe (SDS >5).

Non inferiority of adenosine/dipyridamole compared to adenosine alonewas performed using a unilateral paired t-test, taking α=0.05 and Δ=2 asthe clinical bound under which the difference between the two treatmentscan be considered negligible. Concordance between the summed differencescores of the two methods was evaluated with the Kappa coefficient andthe test of kappa (H0: Kappa coefficient=0.4).

There was a total of 56 patients included in the study however only 40of them (who received the same total dose) were considered in thestatistical analysis. The 16 patients who were not included in thisanalysis received doses of dipyridamole (28-35 μg/kg) in the combinationthat were less than the final dose (70 μg/kg/min+40 μg/kg dipyridamolecombination) therefore it was not considered appropriate to include themin the statistical analysis.

The combination stressor of 40 μg/kg dipyridamole and 70 μg/kg/minadenosine given sequentially was tested and showed equivalent, andsometimes better results, than Adenoscan in terms of imaging efficacy ina series of ten consecutive patients Table 12 shows the stress scores(correlated to myocardial defects) for the first 10 patients of this 40μg/kg series (see “Series I—sequential administration”).

TABLE 12 SDS.A SDS.C Series I (Adenoscan) (SC) Delta score Patient 1 5 41 Patient 2 13 11 2 Patient 3 5 5 0 Patient 4 4 4 0 Patient 5 7 7.5 −0.5Patient 6 5 5 0 Patient 7 4 3 1 Patient 8 14 14 0 Patient 9 5 12.5 −7.5Patient 10 5 6 −1 Total −5 Mean −0.5 Wilcoxon unilateral P = 0.003 (α =0.05) SDS = summed difference scores

A 100% agreement on myocardial defects summed stress scored ≧2 was foundin this first series of 10 patients who received the combinationsequentially (a 4 minute adenosine 70 μg/kg/min continuous IV infusionpreceded by a bolus injection of dipyridamole 40 μg/kg) along with anegative total delta-score and a p value of 0.003 showing that thecombination is non inferior to the reference drug.

A second series of 30 patients received the combination concurrently(adenosine 70 μg/kg/min with dipyridamole 10 μg/kg/min) for 4 minutes.Results are summarized in Table 13.

TABLE 13 Concurrent administration-n = 30 pts Delta score Total −6 Mean0.2 Unilateral paired T-test p < 0.0001 (α = 0.05)

Unilateral paired t-test showed a p value <0.0001 for both theconcurrent administration group (n=30) and the total sample (n=40),thereby demonstrating that Adenosoft (adenosine/dipyridamole) is noninferior to Adenoscan (adenosine alone). The agreement rate for theseverity of reversible defects based on an absolute difference ≦2between the two summed stress scores was 73.3%. Concordance using 5 (SDS≦5 or >5) as the threshold between severe and not severe reversibledefects provided a kappa coefficient of 0.74 [0.50-0.97] for theconcurrent administration group (n=30).

A computerized quantification of Summed Stress Scores and resultingdelta scores was also performed and confirmed that there is nosignificant difference between Adenoscan and Adenosoft. Using thisapproach Mean delta score value was of −1 in the n=10 sequential group(p value=0.004) and of 0.36 in the n=30 concurrent group (p<0.0001).

With respect to patient tolerance in the largest series (n=30-concurrentadministration): The occurrence of A2 symptoms with Adenosoft (ascompared to Adenoscan) was reduced by 23% for dyspnea and 24% forflushing (not statistically significant). That of headache and ofgastrointestinal discomfort was reduced by 20% and 45%, respectively(not statistically significant due to the low number of patients withthese symptoms). The reduction of the occurrence of chest pain (A1 sideeffect) was reduced by 43% (p=0.003).

The severity of dyspnea and flushing was reduced by 49% and 51% (p=0.01and 0.03), that of headache and of gastrointestinal discomfort, by 18%(not statistically significant) and 62.5% (p=0.06, close to statisticalsignificance), respectively. The reduction of chest pain severity wasreduced by 61% (p=0.001).

The summed score of the three main adverse symptoms forming thecomposite index was reduced by 53% with the combination compared toadenosine alone. This decrease was statistically significant (p<0.0001).

No bronchospasm was observed with either drug in this study.

There were no serious adverse effects or any event requiringhospitalization.

EKG changes: ST-T changes occurrence rate was significantly reduced by67% with Adenosoft, as compared to Adenoscan in the total sample (n=40)and by 62% in the concurrent administration group alone. This differencewas significant when considering the total sample (p=0.03) but not whenconsidering the concurrent administration group alone (p=0.06) due tothe lower number of patients. One AV-block of second grade was observedwith the two compounds in the same patient, but the number of episodeswas higher with Adenoscan than with Adenosoft.

Hemodynamic responses: No statistically significant difference wasobserved between the two compounds regarding blood pressure. However,heart rate was significantly lower (p=0.0005) during infusion withAdenosoft. Within 3 to 4 minutes after the end of the perfusion, bothheart rate and blood pressure were at similar levels (lower HR withAdenosoft on average) with no statistical difference, suggesting asimilar PK pattern for the two products.

Tolerance in the sequential administration (with dipyridamole 40 μg/kgimmediately followed by adenosine 70 μg/kg/min) showed a clear trendtowards a reduction of the severity of side effects in the combinationgroup versus Adenoscan. However the difference did not reach statisticalsignificance due to the small sample size studied (n=10).

Conclusion: Adenosoft is better tolerated by patients than Adenoscan.Most important side effects are significantly reduced in severity andoccurrence with the combination of adenosine and dipyridamole.

5.3. Example 3 Concurrent Administration-Reduction of InfusionTime-Assessment of Coronary Reserve by Transthoracic Doppler-Echo Study

An additional study of concurrent administration of dipyridamole 10μg/kg/min with adenosine 70 μg/kg/min for two minutes was also performedusing trans-thoracic doppler echography. The study compared thecombination of adenosine and dipyridamole to adenosine alone given atits standard dosage (140 mg/kg/min) during the same period of time in 31coronary patients assessed for coronary arterial flow reserve. Theprotocol was similar to that described in Example 1 for the sequentialadministration study: adenosine alone was infused first followed by a 5minute interval at baseline and by the infusion of the combinationthereafter.

Primary efficacy end-points were peak and mean diastolic flow velocities(their measurements reflect coronary blood flow values). The secondaryend-point was patient's tolerance to the procedure.

Again results showed that the combination was as effective as adenosinewith no statistical difference between the two methods (p>0.05) for bothmean and peak velocities but significantly better tolerated. Results aresummarized in Table 14 to 16.

TABLE 14 Adenosine/ Adenosine alone dipyridamole P Value Mean velocityat baseline 25.2 ± 8.9  25.5 ± 9.6  0.25 Peak velocity at baseline 33.0± 12.9 33.8 ± 14.2 0.20 Delta mean velocity 41.5 ± 15.3 42.5 ± 15.2 0.50Delta peak velocity 54.4 ± 20.5 56.6 ± 21.1 0.26 “MV-BL” = mean velocityat rest (baseline) - “PV-BL” = peak velocity at rest (baseline) -“MV-STR” = mean velocity under stressing agent infusion - “PV-STR” =peak velocity under stressing agent infusion. Delta = peak-BL.

Results also demonstrated that coronary reserve assessments are the samewith the two products showing no statistical difference between them(P>0.05).

TABLE 15 Adenosine/ Adenosine alone dipyridamole P Value Coronaryreserve assessment 2.79 ± 0.90 2.79 ± 0.86 0.98 using mean velocityCoronary reserve assessment 2.82 ± 0.96 2.85 ± 0.94 0.64 using peakvelocity

With respect to tolerance there was no clear difference in this seriesregarding the occurrence of adverse events between the two products.However a significant difference in the severity of symptoms was againobserved as can be seen in Table 16 with further decrease of A2 sideeffects severity [dyspnea by 33% (p=0.001) and flushing by 77%(p=0.008)] by comparison to the first TTDE study results described inExample 1. This is likely to be due to the reduction in infusion time to2 minutes instead of 3 minutes as in the previous TTDE study.

Table 16. Severity of the main symptoms (fixed concurrent dose adenosine70 μg/kg/min+dipyridamole 10 Ξg/kg/min vs. adenosine 140 μg/kg/min).

TABLE 16 Adenosine alone Adenosine/dipyridamole P Chest pain 0.68 ± 1.870.23 ± 0.96 0.12 Dyspnea 3.64 ± 3.67 2.39 ± 3.06 0.001 Flushing 4.50 ±3.15 3.00 ± 2.67 0.008 Composite index* 8.82 ± 5.62 5.61 ± 4.62 0.0002Composite index = Chest pain, dyspnea and flushing Only 4 patients inthe adenosine group and 2 patients in the combination group experiencedthoracic discomfort in this series explaining the lack of statisticalsignificance for this symptom in the combination treated group versusadenosine alone treated subjects.

5.4. Example 4 Priming Dose Effect

Combination treatment remained equivalent to treatment with thereference drug when infusion time was reduced to 2 minutes from 3minutes as described in Example 1. Reducing the time of infusion (from 3to 2 minutes for TTDE studies and from 4 to 3 minutes for SPECT studiesand possibly less) can further reduce the incidence and severity of sideeffects.

It is known that, in addition to being absorbed by red blood cells,adenosine is taken up and eliminated by the lungs; inhibition of thiselimination by dipyridamole produces an elevated concentration ofendogenous adenosine in the heart; and the dipyridamole effect occursrapidly (e.g in less than ten seconds at 0° Celsius in humanerythrocytes). At 37° Celsius the dipyridamole inhibitory effect on thecapture of adenosine by red blood cells, platelets and endothelial cells(mainly at the pulmonary capillary bed level) is presumed to take longertime than at low temperatures because adenosine uptake velocity is thenincreased about three fold. The study results described in Example 3 andwith a total infusion time of 2 minutes and measurements performedbetween 45 to 90 seconds, suggests that dipyridamole effect becomeseffective after a very short period of time in the order of no more thantwo to three dozen of seconds. In the guinea-pig, whose sensitivity todipyridamole is very close to that of human, the ¹⁴C-content of thelungs following an intravenous injection of ¹⁴C-adenosine, is loweredafter only 20 seconds by low doses of dipyridamole while that of theheart is increased (see Table 17 below—Kolassa & al., European JPharmacology, 1971,13,320,-325).

TABLE 17 Pretreatment Lungs Heart Controls (n = 5) 81 ± 5.5 1.7 ± 0.6Dipyridamole 0.025 mg (n = 5) 71.4 ± 4.9 (p < 0.05) 2.1 ± 1.01 ¹⁴Cdistribution after ¹⁴C-adenosine intravenous injection-Mean values as apercentage of ¹⁴C administered

As a test, a low priming dose of dipyridamole was combined with theconcurrent administration of the two drugs to determine whether the timeto peak and the occurrence of near maximal hyperaemia could beaccelerated, especially when infusion time is reduced by, for example,one minute.

I assessed the effects of several dipyridamole priming doses bymeasuring time to peak (as reflecting differences in adenosineconcentration in the heart) in a series of patients with normal coronaryreserve. Patients were divided into 4 parallel groups (n=3 to 6) whoreceived a 3 minute infusion of adenosine alone at 140 μg/kg/min,followed by a 5 minute interval at baseline, and thereafter a concurrentadministration of 70 μg/kg/min adenosine with 10 μg/kg/min dipyridamole,this concurrent administration performed according to three differentprotocols: (i) without a dipyridamole priming dose (n=6) or (ii)preceded by a priming dose (n=12) of either 0.05 mg, 0.1 or 0.3 mg(representing a fraction of the total dose) injected via a Y connectorinto the infusion line.

In 3 consecutive patients a dipyridamole priming dose of 0.05 mg did notmodify time to peak, so this dose was not explored further. In 3 otherconsecutive patients, a priming dose of 0.1 mg did modify this parameter(see Table 17 and 18) so that a total of 6 patients were studied at thisdose. Three more patients received a priming dose of 0.3 mg that did notperform better than 0.1 mg, so that no additional subjects were exploredat this dose

TABLE 18 Concurrent administration without N = 6 PTS ADE dipyridamolepriming dose Time is [140 μg/ C [Dip 10 μg/kg/min + Ade expressed inseconds kg/min] 70 μg/kg/min] Time to peak pt 1 85 90 Time to peak pt 280 110 Time to peak pt 3 75 85 Time to peak pt 4 56 58 Time to peak pt 5120 130 Time to peak pt 6 50 60 Total 416 533 Mean 69.3 88.8 Return toBL pt 1 75 100 Return to BL pt 2 60 60 Return to BL pt 3 100 111 Returnto BL pt 4 48 63 Return to BL pt 5 60 55 Return to BL pt 6 60 79 Total403 468 Mean 67.1 78 N = 6 PTS Concurrent administration with Time isdipyridamole priming dose (0.1 mg) expressed in seconds ADE C Time topeak pt 1 74 60 Time to peak pt 2 55 70 Time to peak pt 3 45 60 Time topeak pt 4 44 46 Time to peak pt 5 30 35 Time to peak pt 6 40 42 Total288 313 Mean 48 52.1 Return to BL pt 1 55 80 Return to BL pt 2 65 85Return to BL pt 3 54 60 Return to BL pt 4 67 60 Return to BL pt 5 48 60Return to BL pt 6 60 65 Total 349 350 Mean 58.1 58.3

Results showed that time to peak with the combination is, on average,1.5 minutes versus about 1 minute with adenosine, but approaches that ofadenosine alone (with no change in return to baseline time) when adipyridamole priming dose is administered prior to the concurrentinfusion of the combination. The shortest time to peak being mostappropriate to secure the efficacy of the combination givenconcurrently, this approach appeared to be an improvement of the methodwhatever the total infusion duration. A priming dose of dipyridamole(given prior to the concurrent infusion) and acting as pre-treatment(presumably, but not intending to be bound by theory, by partialinhibition of adenosine capture by pulmonary endothelial cells) canachieve such effect. With regard to tolerance, this method of use canhelp further reduce the total infusion time, thus the total dosereceived by the patient and along with that the occurrence and severityof related side effects

These data suggest that a 3 minute infusion instead of a 4 minuteinfusion could be possibly used for SPECT studies with injection of theisotope after about only 2 minutes. Further, the data suggest that a 2minute infusion instead of a 3 to 4 minute infusion could be used forMCE studies, and especially CT studies, which have the added advantageof being performed without administration of contrast agent.

5.5. Example 5 Priming Dose Effect with the Sequential AdministrationMode

The priming dose effect was also studied in 10 consecutive patients whowere administered the combination sequentially (dipyridamole 40 μg/kg asa 5-10 seconds bolus, followed by adenosine infusion 70 μg/kg/min over 2minutes). Again there was no difference between the two methods for bothpeak and mean velocities. Results show that time to peak and return tobaseline are almost the same between the two method (see Table 19).

TABLE 19 N = 10 PTS Adenosine alone Sequential administration Time isADE [140 C [Dip 40 μg/kg + Ade expressed in seconds μg/kg/min] 70μg/kg/min] Time to peak pt 1 60 60 Time to peak pt 2 90 140 Time to peakpt 3 40 60 Time to peak pt 4 50 60 Time to peak pt 5 70 75 Time to peakpt 6 50 60 Time to peak pt 7 75 80 Time to peak pt 8 60 45 Time to peakpt 9 35 35 Time to peak pt 10 38 36 Total 568 651 Mean 57 65 Return toBL pt 1 30 50 Return to BL pt 2 30 75 Return to BL pt 3 60 65 Return toBL pt 4 50 30 Return to BL pt 5 60 70 Return to BL pt 6 60 80 Return toBL pt 7 35 40 Return to BL pt 8 40 40 Return to BL pt 9 35 25 Return toBL pt 10 28 37 Total 428 512 Mean 43 51

5.6. Example 6 Stability of a Single Unit Dosage Form ComprisingAdenosine and Dipyridamole in the 7:1 Ratio

A study was undertaken to assess pharmacological properties of apharmaceutical composition comprising adenosine and dipyridamole at anA:D weight ratio of 7:1. In particular, the study was conducted toassess the properties of a composition comprising adenosine at aconcentration of 7 mg/ml and dipyridamole at a concentration of 1 mg/ml.This particular formulation is very convenient, since it permits easycalculation of concentrations, maximal volumes, and weights—which isuseful to reduce dosing errors in the clinical setting—while alsocovering a wide range of needs, as shown in the Table 20 below

TABLE 20 Maximal Total Adenosine Total amount patient amount ofconcentration Volume of adenosine weight covered dipyridamole (mg/ml)(ml) per unit (mg) (kgs) per unit (mg) 7 2 14 50 2 3 21 75 3 4 28 100 45 35 125 5 6 42 150 6 8 56 200 8

Dipyridamole is poorly soluble in saline and unstable in the long termin solvents at pH>4. Adenosine compositions currently used in clinicalpractice have pH>4, and are thus poorly suited to addition ofdipyridamole. Therefore, a more acidic pH was chosen. The lower pH alsoincreases adenosine solubility above 4 mg/ml, which is the upperacceptable adenosine concentration limit in saline.

The following composition (Table 21) was prepared:

TABLE 21 Final Component concentration Supplier Reference Adenosine 7mg/ml Sigma Eur.Ph. 01/2005: 1486 Aldrich Dipyridamole 1 mg/ml SigmaEur.Ph. 01/2005: 1199 Aldrich Polyethyleneglycol 50 mg/ml  SASOL Eur.Ph.01/2005: 1444 600 Tartaric acid 2 mg/ml Sigma Eur.Ph. 01/2005: 0460Aldrich Water for injection — (1 ml) Aguettant AMM: 319 508.5

After sonication for 2 minutes and magnetic stirring for 10 minutes, thesolution became completely clear with a pH of 3.6 and an osmolality of151 mosmol/kg. The stability of this composition was studied at varioustemperatures and conditions over a 6 month period of time. Results aresummarized in the Table 22 below.

TABLE 22 Controls Specifications T0 T3 months T6 months Storageconditions: 25° C. ± 2° C.-60% HR ± 5% - Results Characters AppearanceYellowish clear complies complies complies solution pH (3.4) 2.5-4.5 3.63.7 3.6 Osmolality 130-180 mosmol/kg 153 152 147 IdentificationsAdenosine by HPLC The retention time and complies complies compliesDipyridamole by HPLC the UV spectra complies complies complies are thesame as the standard solution for the two products Assays Adenosine byHPLC 0.665-0.735 g/100 ml 0.693 0.686 0.718 Dipyridamole by 0.095-0.105g/100 ml 0.101 0.097 0.094 HPLC Storage conditions: 5° C. ± 3° C. -Results Characters Appearance Yellowish clear solution pH (3.4) 2.5-4.5Osmolality 130-180 mosmol/kg Identifications Adenosine by HPLC Theretention time complies complies complies Dipyridamole by and the UVspectra complies complies complies HPLC are the same as the standardsolution for the two products Assays Adenosine by HPLC 0.665-0.735 g/100ml 0.710 0.707 0.693 Dipyridamole by HP 0.095-0.105 g/100 ml 0.098 0.0980.099

At 30° C. and above (not shown) the stability of the compositionappeared below acceptable specifications after 3 months. At 25° C. and arelative humidity of 60% it appeared slightly under the requiredspecifications (table 22) however some mild modifications brought to theoriginal medium could normalized this result according to known art inthis field. At storage conditions of 5° C. and after 6 months thecomposition as described here appeared perfectly stable and within usualspecifications required.

5.7. Example 7 Specific Labels with Kilogram Graduation Marks forSyringes

A label for synthetic (plastic, resin, polymer, or equivalent) or glasssyringes prefilled with 1 ml of dipyridamole alone (typically 4 mg) withkilo graduation marks on the barrel is designed according to thefollowing recommendations: the label provides 0.01 ml intervals perkilogram such that 1 ml corresponds to 100 kg of patient weight, 0.9 mlcorresponds to 90 kg, 0.8 ml corresponds to 80 kg and so forth. See,e.g., FIG. 2A. Scales and numbers are inscribed on the cylinder(barrel). Mid values (e.g., 95, 85, 75 kg or 0.95, 0.85 or 0.75 ml) aremarked by a longer graduation mark, typically about twice the length ofthe smallest increment on the label (such as, for example 82, 73 or 61kg or 0.82, 0.73 or 0.61 ml). Labels may comprise a scale ranging from10 to 100 kilograms or a more limited scale from 100 to 40 kilos (see,e.g., FIGS. 1A-1B). Labels for larger volume prefilled syringes are alsopossible. For example, labels are feasible for a 2 ml prefilleddipyridamole syringe using the same scale as above but twice as long andranging up to 200 kilograms.

A label for synthetic (plastic, resin, polymer or equivalent) or glasssyringes filled with 10 ml of adenosine alone (typically 28 mg) isdesigned according to the same principle as in the immediately precedingparagraph with several possible intervals depending on the infusiontime. On one label, 1 kilogram is equivalent to 0.1 ml (infusion time=4minutes). On another label 1 kilogram is equivalent to 0.075 ml(infusion time=3 minutes). See, e.g., FIG. 2B. On another label (30 mgadenosine in 10 ml and infusion time 3 minutes), 1 kilogram isequivalent to 0.07 ml.

Labeled pre-filled syringes with joined (yoked) plungers to allow forcoordinated administration of adenosine and dipyridamole are alsoenvisioned. See, e.g., FIG. 6. For example, a 1-ml prefilleddipyridamole syringe and a 10 ml prefilled adenosine syringe can beadjusted in order to be of the same length, and then easily joined byknown means, so that the motion of these two pistons is coordinated. Atthe two open ends of two syringes a connector can be either pushed orscrewed to facilitate the mixing of the two products.

5.8. Example 8 Labels with Kilogram Graduation Marks for Syringes

In some label embodiments, the weight graduation scale is in kilogramsand the scale can range from 10 or 40 kilograms up to 100 or 125 or 133or 150 or 166 or even 200 kilograms depending on the syringe capacity.See FIG. 1. Milliliter per kilogram equivalence can range from 1kilogram=0.0005 ml, to 1 kilogram=1 ml regardless of the syringecharacteristics and more typically from 1 kilogram=0.01 ml, to 1kilogram=0.2 ml.

From the description herein, labels can be readily designed for syringesof varying sizes and volumes. Table 23 below provides examples of threedifferent possible kilogram scales for prefilled syringes ranging from0.1 to 10 ml.

TABLE 23 Kilogram graduation interval in ml (One Prefilled syringekilogram/value in ml) (in milliliters) ml 50 kg 100 kg 125 kg 0.1 0.0020.001 0.0008 0.2 0.004 0.002 0.0016 0.3 0.006 0.003 0.0024 0.4 0.0080.004 0.0032 0.5 0.010 0.005 0.0040 0.6 0.012 0.006 0.0048 0.7 0.0140.007 0.0056 0.8 0.016 0.008 0.0064 0.9 0.018 0.009 0.0072 1 0.02 0.0100.0080 1.5 0.03 0.015 0.012 2 0.04 0.020 0.016 2.5 0.05 0.025 0.020 30.06 0.030 0.024 3.5 0.07 0.035 0.028 4 0.08 0.040 0.032 4.5 0.09 0.0450.036 5 0.10 0.050 0.040 5.5 0.11 0.055 0.044 6 0.12 0.060 0.048 6.50.13 0.065 0.052 7 0.14 0.070 0.056 7.5 0.15 0.075 0.060 8 0.16 0.080.064 8.5 0.17 0.085 0.068 9 0.18 0.09 0.072 9.5 0.19 0.095 0.076 100.20 0.1 0.080

If the label ranges up to 200 kgs, a 1-kg interval is equivalent to (0.1ml/200) or 0.0005 ml. As shown here, for a 10-ml syringe, the greatestml per kg division is 0.2 ml. Similarly, for 20 or 30 ml prefilledsyringes, the greatest ml per kg division is 0.4 ml or 0.6 mlrespectively. Incremental values of ml per kilo can range up to 0.8ml/kg, or even 1 ml/kg.

Labels can be tailored for any desired starting and ending weight.Examples of upper ends of weight scales include, but are not limited to200 kg, 150 kg, or 120 kg. In some cases, the ml per kilo equivalence isfractional rather than a whole number, such as 0.000666 (0.1 ml/150 kg)or 0.006 (1 ml/150 kg) or 0.0008333 (0.1 ml/120 kg) or 0.008333 (1ml/120 kg).

Labels can also be designed for low weight patients (e.g., children) asshown in the 50 kg example above. Equally possible are labels withweight scales ranging up to a maximum of 40 kg or even 30 kg.

In some embodiments, the weight scale is labeled in pounds and the unitinterval is one pound or two pounds corresponding to a certain volume ofactive solution, following the same principle as described forkilograms.

All publications, patents, patent applications and other documents citedin this application are hereby incorporated by reference in theirentireties for all purposes to the same extent as if each individualpublication, patent, patent application or other document wereindividually indicated to be incorporated by reference for all purposes.

While various specific embodiments have been illustrated and described,it will be appreciated that various changes can be made withoutdeparting from the spirit and scope of the invention(s).

1. A pharmaceutical composition comprising adenosine and dipyridamole inan adenosine:dipyridamole weight ratio of about 2:1 to about 10:1. 2.(canceled)
 3. The pharmaceutical composition according to claim 1,wherein adenosine and dipyridamole are present in amounts that permitadenosine to be administered at a dosage rate of 35 to 100 μg/kg/min anddipyridamole to be administered at a dosage rate of 3.5 to 50 μg/kg/min.4. The pharmaceutical composition of claim 3, wherein the composition isa sterile fluid.
 5. The pharmaceutical composition of claim 4, whereinadenosine and dipyridamole are present at concentrations that permitdirect intravenous administration.
 6. (canceled)
 7. The pharmaceuticalcomposition according to claim 1, wherein the concentration of adenosineis about 1 to 10 mg/ml.
 8. (canceled)
 9. The pharmaceutical compositionaccording to claim 1, wherein the concentration of dipyridamole is about0.1 to 4 mg/ml.
 10. The pharmaceutical composition according to claim 9,wherein the concentration of dipyridamole is about 1 mg/ml and theconcentration of adenosine is about 7 mg/ml.
 11. A unit dosage formcomprising about 2 to 50 ml of the composition according to claim 1,wherein the composition is a sterile fluid. 12-18. (canceled)
 19. A unitdosage form comprising about 5 to 60 mg of adenosine and about 0.1 to 10mg of dipyridamole, wherein the composition is a solid capable ofsterile reconstitution in a physiologically acceptable solvent orsolution. 20-24. (canceled)
 25. A unit dosage form of dipyridamole,comprising dipyridamole at a concentration of 0.1 to 4 mg/ml. 26-30.(canceled)
 31. A unit dosage form of adenosine, formulated in sterilefluid composition, wherein the dose packaging permits sterileintroduction of a second fluid in a volume at least 15% that of theadenosine composition.
 32. The unit dosage form of claim 31, comprising21 mg adenosine in 6 ml.
 33. The unit dosage form of claim 31,comprising 28 mg adenosine in 6 ml.
 34. The unit dosage form of claim31, comprising 42 mg adenosine in 12 ml.
 35. The unit dosage form ofclaim 31, comprising 56 mg adenosine in 12 ml.
 36. The unit dosage formof claim 31, comprising 35 mg adenosine in 14 ml.
 37. A unit dosage formof adenosine, formulated in sterile fluid composition, comprisingadenosine at a concentration of about 2 to about 4 mg/ml.
 38. (canceled)39. The unit dosage form of claim 37, comprising 21 mg adenosine in 7ml.
 40. The unit dosage form of claim 37, comprising 42 mg adenosine in14 ml.
 41. The unit dosage form of claim 38, comprising 28 mg adenosinein 7 ml.
 42. The unit dosage form of claim 38 comprising 56 mg in 14 ml.43. A unit dosage form of adenosine, formulated in sterile fluidcomposition, comprising adenosine at a concentration of about 2.1 mg/ml.44. A unit dosage form of adenosine, formulated in sterile fluidcomposition, comprising adenosine at a concentration of about 2.8 mg/ml.45-48. (canceled)
 49. A label for dose adjustment based on patientweight, the label capable of being affixed to a delivery device andcomprising at least one graduated scale in units of weight.
 50. Thelabel according to claim 49, comprising one or more graduation scalespermitting the dosing of dipyridamole alone, adenosine alone, or acomposition comprising adenosine and dipyridamole.
 51. The label ofclaim 50, affixed to a prefilled syringe comprising a pharmaceuticalcomposition of adenosine alone, dipyridamole alone, or both incombination.
 52. The label of claim 51 for prefilled syringes withdipyridamole alone wherein a 1 kilogram interval is equivalent to 0.01ml.
 53. The label of claim 49 for prefilled syringes comprising asolution of adenosine alone wherein a one kilogram interval on the scaleis equivalent to 0.06 ml, 0.07 ml, 0.075 ml, 0.08 ml, 0.09 ml, 0.1 ml or0.12 ml.
 54. A kit comprising at least one unit dosage form ofdipyridamole and at least one unit dosage form of adenosine. 55-56.(canceled)
 57. A method of effecting coronary vasodilation for cardiacdiagnosis, the method comprising: concurrently administering adenosineand dipyridamole, from a single unit dosage form or from separate unitdosage forms, optionally with a dipyridamole priming dose prior to theirconcurrent infusion, and wherein adenosine and dipyridamole areadministered parenterally at an adenosine:dipyridamole weight ratio ofabout 2:1 to about 10:1.
 58. (canceled)
 59. The method of claim 57,wherein adenosine is administered at a dosage rate of 35 to 100μg/kg/min and dipyridamole is administered at a dosage rate of 3.5 to 50μg/kg/min.
 60. The method of claim 57 wherein adenosine is administeredat a dosage rate of 70 μg/kg/min and dipyridamole is administered at adosage rate of 10 μg/kg/min.
 61. The method of claim 57 wherein adipyridamole priming dose of about 0.05 to 0.5 mg is administered priorto concurrent administration of adenosine with dipyridamole. 62.(canceled)
 63. The method of claim 57 wherein adenosine and dipyridamoleare administered concurrently from separate unit dosage forms andcompositions.
 64. The method of claim 63 wherein adenosine anddipyridamole are administered concurrently from separate, interconnectedsyringes.
 65. The method of claim 57, wherein adenosine and dipyridamoleare parenterally administered continuously for a period of about 1 to 6minutes. 66-69. (canceled)
 70. The method of claim 57, wherein theadenosine and dipyridamole compositions are administered by intravenousinfusion.
 71. The method of claim 57, wherein the adenosine anddipyridamole compositions are administered intra-arterially.
 72. Themethod of claim 57, further comprising the step of assessing cardiacfunction.
 73. The method of claim 72, wherein assessing cardiac functionincludes use of one or more techniques selected from the groupconsisting of: electrocardiography, M mode echography, two dimensionalechography, three dimensional echography, echo-doppler, cardiac imaging,planar (conventional) scintigraphy, single photon emission computedtomography (SPECT), dynamic single photon emission computed tomography,positron emission tomography (PET), first pass radionuclide angiography,equilibrium radionuclide angiography, nuclear magnetic resonance (NMR)imaging, myocardial perfusion contrast echocardiography, digitalsubtraction angiography (DSA), x-ray computed tomography (CINE CT), highspeed and ultra high speed computed tomography scan. 75-78. (canceled)79. The method of any one of claim 72, wherein cardiac functionassessment includes parenteral administration of an isotope, and whereinthe isotope is administered after 2 minutes and before 3 minutes fromthe start of the concurrent parenteral administration of adenosine anddipyridamole.
 80. (canceled)
 81. A method of effecting coronaryvasodilation for cardiac diagnosis, the method comprising parenterallyadministering dipyridamole as a pretreatment; and sequentiallythereafter parenterally administering an adenosine receptor agonist,wherein each of dipyridamole and said adenosine receptor agonist isadministered at a dosage lower than that required for maximal coronaryvasodilation when administered as a single agent by identical parenteralroute.
 82. The method of claim 81, wherein the adenosine receptoragonist is selected from the group consisting of: adenosine, adenosinetriphosphate, adenosine diphosphate, adenosine monophosphate, andpro-drugs and pharmaceutically acceptable salts thereof and wherein theadenosine agonist: dipyridamole ratio is of about 2:1 to about 10:1. 83.The method of claim 81, wherein each route of parenteral administrationis independently selected from the group consisting of: intra-arterial,intravenous, intra-coronary, and atrial administration.
 84. The methodof claims 81, wherein dipyridamole is administered by intravenous bolusinjection prior to adenosine agonist infusion.
 85. The method of claim81, wherein dipyridamole is administered as an intravenous orintra-arterial bolus at a dosage of 14 to 140 μg/kg and adenosineintracoronarily at the dose of 10-20 μg/min for up to a maximum of about6 minutes.
 86. (canceled)
 87. The method of claim 81 whereindipyridamole is administered intravenously as a bolus over 5 to 30seconds.
 88. The method of claim 81, wherein administration of theadenosine receptor agonist is begun immediately after completion ofdipyridamole administration.
 89. The method of claim 88, whereinadenosine receptor agonist is infused intravenously for about 1 to about6 minutes after dipyridamole injection. 90-92. (canceled)
 93. The methodaccording to claim 81, wherein the adenosine receptor agonist isadenosine, administered by intravenous infusion at a dosage rate of 35to 100 μg/kg/min.
 94. The method of claim 93, wherein adenosine isadministered at a dosage rate of about 70 μg/kg/min.
 95. The method ofclaim 81, wherein dipyridamole is administered intravenously andadenosine is administered intravenously.
 96. The method of claim 81wherein the adenosine receptor agonist is adenosine, the total dose ofdipyridamole is 23 to 40 μg/kg, and the dosage rate for adenosine is 50to 70 μg/kg/min.
 97. (canceled)
 98. The method of claim 81, furthercomprising the step of: assessing cardiac function.
 99. The method ofclaim 98, wherein the step of assessing cardiac function includes use ofone or more techniques selected from the group consisting of:electrocardiography, M mode echography, two dimensional echography,three dimensional echography, echo-doppler, cardiac imaging, planar(conventional) scintigraphy, single photon emission computed tomography(SPECT), dynamic single photon emission computed tomography, positronemission tomography (PET), first pass radionuclide angiography,equilibrium radionuclide angiography, nuclear magnetic resonance (NMR)imaging, myocardial perfusion contrast echocardiography, digitalsubtraction angiography (DSA), x-ray computed tomography (CINE CT), highspeed CT scan, and ultra high speed CT scan. 100-103. (canceled) 104.The method of claim 99 wherein the isotope is injected after 2 andbefore 3 minutes after the start of adenosine receptor agonist infusion.105. The method of claim 99 wherein assessing cardiac function includesparenteral administration or formation of any agent detectable byultrasound techniques into the coronary artery network.
 106. The unitdosage form of claim 37, comprising 14 mg adenosine in 7 ml.
 107. Thelabel of claim 49, wherein the delivery device is a syringe.
 108. Thelabel of claim 107, wherein the syringe has a total capacity of 1 to 30ml.
 109. The label of claim 49, wherein the unit of weight is akilogram.
 110. The label of claim 109, wherein the scale ranges from aminimum of about 10-40 kg to a maximum of about 100-200 kg.
 111. Thelabel of claim 49, wherein the unit of weight is a pound.
 112. The labelof claim 49, further comprising a graduated scale in units of volume.113. The label of claim 112, wherein a 1 kg interval corresponds to avolume ranging from 0.0005 ml to 1 ml.
 114. The label according to claim51, wherein the prefilled syringe contains a composition comprising 60mg of adenosine in 20 ml in a prefilled syringe.
 115. The labelaccording to claim 51, wherein the prefilled syringe contains acomposition comprising 90 mg of adenosine in 30 ml in a prefilledsyringe.
 116. The method of claim 72, wherein the cardiac functionassessed is myocardial perfusion or vasodilation of a coronary artery.117-119. (canceled)
 120. The label of claim 49 for prefilled syringescomprising a solution of adenosine alone wherein a one kilogram intervalon the scale is equivalent to 0.03 ml, 0.04 ml, 0.042 ml, 0.0525 ml,0.056 ml, or 0.07 ml.